WMH OR Housekeeping

• Conducted on

  Date

• Prepared by

• Personnel

OR #1

• 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

OR #2

• 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

OR #3

• 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

OR #4

• 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

OR #5

• 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

OR #6

• 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

OR #7

• 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

OR #8

• 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

OR #9

• 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

OR #10

• 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

OR #11

• 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

OR #12

• 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

OR #14

• 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

OR #15

• 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

OR #16

• 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

OR GU Room

• 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