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Date:Room Number:Unit:Initials of ES staff (optional):Observer:
Evaluate the following priority sites for each patient room:
High-touch Room Surfaces1CleanedNot 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 handle
Evaluate other areas requiring cleaning:
Additional areasCleanedNot CleanedNot Present in RoomCubicle and/or window curtainsFloorsWalls if soiledBedside commode if applicable
Evaluate the following additional sites if these equipment are present in the room:
High-touch Room Surfaces1CleanedNot CleanedNot Present in RoomOxygen concentratorIV pole / 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
1Sites most frequently contaminated and touched by patients and/or healthcare workers
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