WMH GI Center Housekeeping

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

GI #B712

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B713

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B714

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B715

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B716

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B717

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B718

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A

GI #B719

• Procedure room surface counters, cabinets, and all surfaces are clean and free of dust.

  Yes

  No

  N/A

• Procedure room furniture, metal tables, and carts are clean and dust free.

  Yes

  No

  N/A

• Procedural room lights are clean and dust free.

  Yes

  No

  N/A

• Procedure cart/bed is clean and free of dust, blood or body fluids.

  Yes

  No

  N/A

• Procedure room booms, cords, and hoses are free of dust, blood or other fluids/soiling.

  Yes

  No

  N/A

• The procedural floor is clean and free of soiling or blood and body fluids.

  Yes

  No

  N/A

• Procedural room trash and biohazardous waste has been removed and disposed of properly.

  Yes

  No

  N/A

• All soiled linen has been removed from procedural room.

  Yes

  No

  N/A

• Vents are free of dust and debris.

  Yes

  No

  N/A