Page 1
Sign In
Location
Date
Time
Name
General Patient Care Area
Hand hygiene available and in use?
Personal protective equipment (PPE) available and in use?
Environment clean and uncluttered?
Necessary patient equipment clean and in good repair?
Patient Room
Hand hygiene available and in use?
Personal protective equipment (PPE) available and in use?
Environment clean and uncluttered?
Necessary patient equipment clean and in good repair?
Patient has proper signage for isolation precautions?
Nursing Station
Hand hygiene available and in use?
Personal protective equipment (PPE) available and in use?
Environment clean and uncluttered?
Necessary equipment clean and in good repair?
Sign Off
Signature
Date
Time