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Date:Unit:Room Number:Initials of ES staff (optional):2
Evaluate the following priority sites for each patient room:
High-touch Room Surfaces3CleanedNot CleanedNot Present in RoomBed rails / controlsTray tableIV pole (grab area)Call box / buttonTelephoneBedside table handleChairRoom sink Room light switchRoom inner door knobBathroom inner door knob / plateBathroom light switchBathroom handrails by toiletBathroom sink Toilet seatToilet flush handleToilet bedpan cleaner
Evaluate the following additional sites if these equipment are present in the room:
High-touch Room Surfaces3CleanedNot CleanedNot Present in RoomIV pump controlMulti-module monitor controlsMulti-module monitor touch screenMulti-module monitor cablesVentilator control panel
Mark the monitoring method used:
Direct observation Fluorescent gel
Swab cultures ATP system Agar slide cultures
____________________________
1Selection of detergents and disinfectants should be according to institutional policies and procedures
2Hospitals may choose to include identifiers of individual environmental services staff for feedback purposes.
3Sites most frequently contaminated and touched by patients and/or healthcare workers
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