Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location

Treatment and Examination Rooms

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Furniture is clean and in good condition

  • Curtains are clean and free of tears

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • PPE is available

  • No expired supplies

  • No staff food or beverages

  • Additional findings

Clean Utility and Storage Rooms

  • Door is closed and locked if appropriate

  • Area is clean

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Adequate separation of clean and soiled

  • No supplies stored on the floor

  • Bottom shelf barriers are in place and are 6 inches from the floor

  • Items stored are 18 inches from the ceiling

  • Equipment stored is clean

  • No expired supplies

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • Additional findings

Soiled Utility Room

  • Door is closed and locked if appropriate

  • Area is clean and orderly

  • Area is free of clean patient supplies and sterilized trays

  • Countertops are clean and in good condition

  • Shelving/drawers/cabinets are clean and in good condition

  • Separate sinks are available for handwashing and for cleaning soiled instruments if appropriate

  • Sinks are clean and in good condition

  • Nothing inappropriate is stored under the sinks

  • Soiled linen is bagged and placed in appropriate receptacle

  • Process flow is dirty to clean (if applicable)

  • Additional findings

Laboratory

  • Furniture is clean and in good condition

  • No expired supplies

  • No staff food or beverages

  • Specimens are bagged, handled, and labeled as per policy (if observed)

  • Additional findings

Offices, Work Stations, and Reception Areas

  • Desks are clean, not cluttered, and free from patient care items

  • Food and beverages are only in designated areas

  • Beverages are covered in areas where the policy allows beverages

  • Additional findings

Meeting Rooms and Staff Lounges

  • Furniture is clean and in good condition

  • Area is clean and items are appropriately stored

  • No patient care items

  • Additional findings

Waiting Areas and Hallways

  • Hallways are clean and not cluttered

  • Furniture is clean and in good condition

  • Area is clean and items are appropriately stored

  • Additional findings

Equipment and Non-Critical Items

  • Computer equipment is clean, in good condition, and with no tape

  • Equipment is clean

  • Additional findings

Linen

  • There is separation of clean and soiled linen

  • Clean linen is stored in required area, on shelves, or on covered carts

  • Soiled linen is not placed on floor, furniture, windowsills, etc. and is not overfilled

  • Linen hampers and carts are clean and in good condition

  • Linen is transported appropriately

  • Additional findings

Refrigerators

  • Only medications are present in medication refrigerator

  • Only food is present in food refrigerator

  • Only specimens are present in specimen refrigerator

  • Patient and staff food/beverages are not mixed

  • Refrigerators are clean and in good condition

  • Items in refrigerators are labeled as per policy

  • No expired items

  • Additional findings

Medications

  • No outdated/expired medications

  • Open vials are dated and timed as per policy

  • Medication carts are clean and organized

  • Additional findings

Waste Management

  • Biohazard bags are used appropriately

  • Waste containers are clean, operational, in good condition, and not overfilled

  • Waste containers are covered and labeled as required

  • Red bag is available in regulated waste container

  • Items in regulated medical waste containers are appropriate

  • Sharps container is available, secured appropriately, and not overfilled

  • Additional findings

Hand Hygiene

  • Hand hygiene is performed when appropriate (if observed)

  • Appropriate glove use (if observed)

  • Sinks are available, clean, and in good condition

  • Soap is available and not expired

  • Paper towels are available

  • Alcohol-based hand rub is available and not expired

  • Additional findings

General Environment

  • Floors are clean and in good condition

  • Walls are clean and in good condition

  • Ceiling is clean and in good condition

  • Air vents are clean and in good condition

  • Light fixtures are clean and in good condition

  • High-level dusting is performed

  • Area is free of roaches, flies, mice, and other vermin

  • Additional findings

Miscellaneous

  • Signage is laminated and not taped

  • No inappropriate items on windowsills

  • Cleaning supplies are not stored with patient care items

  • Sterilized items are not expired, free of dust/tears, and not opened

  • Items are labeled/dated appropriately (electrodes, ultrasound gel, etc.)

  • No outside shipping/corrugated cardboard boxes

  • No items/surfaces that cannot be cleaned in patient care areas

  • Eyewash stations are checked weekly and documented on the tag

  • Additional findings

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.