Checklist template

Exam room readiness for medical clinics

A ready-to-use checklist with 120 items in 6 sections, covering Cleanliness, Supplies, Equipment, Turnover between patients, Privacy, Stocking. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 6 Sections
  • 120 Items
  • 105 Yes / No checks
  • 6 Scored ratings
  • 135 Points

Use this template How audits work

1. Cleanliness 22 items

  1. Exam rooms inspected during the visit Number
  2. The exam table upholstery is free of tears and cracks Yes / No 1 pt
  3. The exam table is visibly clean under the paper Yes / No 1 pt
  4. Counter tops hold only the items on the room standard Yes / No 1 pt
  5. The tops of cabinets and wall-mounted instrument units are free of dust Yes / No 1 pt
  6. The floor is free of debris, including corners and under the exam table Yes / No 1 pt
  7. The sink basin and faucet are clean Yes / No 1 pt
  8. No supplies are kept on the sink rim or within splash distance of the faucet Yes / No 1 pt
  9. Nothing is stored in the cabinet under the sink Yes / No 1 pt
  10. The trash can is less than three-quarters full Yes / No 1 pt
  11. The sharps container is below its fill line Yes / No 1 pt
  12. The sharps container is mounted or secured out of reach of small children Yes / No 1 pt
  13. The biohazard waste bin has a lid and a red liner Yes / No 1 pt
  14. The privacy curtain is free of stains Yes / No 1 pt
  15. The privacy curtain carries a change date within the company schedule Yes / No 1 pt
  16. Walls and baseboards are free of splashes and tape residue Yes / No 1 pt
  17. Ceiling vents are free of dust build-up Yes / No 1 pt
  18. The keyboard and mouse are visibly clean Yes / No 1 pt
  19. Chairs for patients and companions have wipeable covers with no tears Yes / No 1 pt
  20. No staff food or drink is in the room Yes / No 1 pt
  21. The daily cleaning checklist for the room is initialed for each of the last 5 clinic days Yes / No 1 pt
  22. Cleanliness of the exam rooms inspected Rating
    • Clean in every room 5 pts
    • Minor lapses in one or two rooms 3 pts
    • Visibly dirty surfaces or overfilled waste 1 pt

2. Supplies 20 items

  1. Exam gloves are in the wall holder in at least two sizes Yes / No 1 pt
  2. The hand soap dispenser at the sink dispenses soap Yes / No 1 pt
  3. The paper towel dispenser is filled Yes / No 1 pt
  4. The alcohol hand rub dispenser at the door works Yes / No 1 pt
  5. The hand rub cartridge is within its expiry date Yes / No 1 pt
  6. A roll of table paper is loaded on the exam table Yes / No 1 pt
  7. A spare roll of table paper is in the room Yes / No 1 pt
  8. Patient gowns are in the drawer in more than one size Yes / No 1 pt
  9. Disposable drapes are in the room Yes / No 1 pt
  10. The disinfectant wipe canister is closed, with moist wipes Yes / No 1 pt
  11. Tongue depressors are kept in a covered container Yes / No 1 pt
  12. Cotton-tipped applicators are kept in a covered container Yes / No 1 pt
  13. Otoscope specula are stocked in adult and pediatric sizes Yes / No 1 pt
  14. Thermometer probe covers are stocked at the thermometer Yes / No 1 pt
  15. Lubricating jelly is stocked as single-use packets Yes / No 1 pt
  16. Alcohol prep pads, gauze and adhesive bandages are in their labeled drawer Yes / No 1 pt
  17. Emesis bags are within reach of the exam table Yes / No 1 pt
  18. Opened multi-use containers (ultrasound gel, skin cleanser) are labeled with the date opened Yes / No 1 pt
  19. Expired items found among 10 items drawn from the drawers of each room Number
  20. Point-of-use supplies in the rooms inspected Rating
    • Everything on the room standard present 5 pts
    • A few items missing 3 pts
    • Items missing that would interrupt a visit 1 pt

3. Equipment 22 items

  1. The exam table moves through its positions Yes / No 1 pt
  2. The stirrups or leg rest extend and lock Yes / No 1 pt
  3. The exam light switches on and holds its position Yes / No 1 pt
  4. The otoscope and ophthalmoscope light up when lifted from the wall unit Yes / No 1 pt
  5. Blood pressure cuffs are in the room in adult, large adult and pediatric sizes Yes / No 1 pt
  6. The blood pressure unit inflates and holds pressure Yes / No 1 pt
  7. Blood pressure tubing is free of cracks Yes / No 1 pt
  8. The thermometer powers on and completes its self-test Yes / No 1 pt
  9. The pulse oximeter powers on and gives a reading on a test finger Yes / No 1 pt
  10. The scale reads zero when empty Yes / No 1 pt
  11. The scale carries a calibration sticker within date Yes / No 1 pt
  12. Each powered device carries a biomedical inspection sticker within date Yes / No 1 pt
  13. The computer in the room starts and reaches the sign-in screen Yes / No 1 pt
  14. The screen can be turned so the provider faces the patient while typing Yes / No 1 pt
  15. The staff call button or light works when tested Yes / No 1 pt
  16. The provider stool rolls freely and is stable Yes / No 1 pt
  17. Electrical cords are intact, with no extension cords in use Yes / No 1 pt
  18. Wall oxygen or suction, where fitted, has tubing and a canister attached Yes / No 1 pt
  19. No out-of-service equipment is left in the room Yes / No 1 pt
  20. Equipment waiting for repair is tagged with the date and the fault Yes / No 1 pt
  21. Oldest biomedical inspection date found on a device in the rooms inspected Date
  22. Working condition of exam room equipment Rating
    • All working and in date 5 pts
    • One device faulty or out of date 3 pts
    • Several devices faulty or out of date 1 pt

4. Turnover between patients 19 items

  1. Room turnovers observed during the visit Number
  2. The table paper was changed after every patient observed Yes / No 1 pt
  3. The exam table was wiped with disinfectant between patients Yes / No 1 pt
  4. Door handles, chair arms and the counter were wiped between patients Yes / No 1 pt
  5. The employee asked could state the wet contact time printed on the disinfectant label Yes / No 1 pt
  6. Surfaces stayed wet for the contact time before the next patient was brought in Yes / No 1 pt
  7. The blood pressure cuff was wiped between patients Yes / No 1 pt
  8. The pulse oximeter probe was wiped between patients Yes / No 1 pt
  9. Used gowns and drapes were removed before the next patient entered Yes / No 1 pt
  10. Used instruments went into a closed, labeled transport container rather than staying on the counter Yes / No 1 pt
  11. Specimens were taken out of the room before the next patient entered Yes / No 1 pt
  12. Labels and paperwork of the previous patient were removed from the room Yes / No 1 pt
  13. The previous patient's record was closed on the screen before the next patient entered Yes / No 1 pt
  14. The employee cleaned their hands after turning the room over Yes / No 1 pt
  15. The room flag, light or system status was set to show the room ready Yes / No 1 pt
  16. The employee asked could describe the extra cleaning steps after a patient with a suspected contagious illness Yes / No 1 pt
  17. Rooms not used yesterday were checked this morning before the first patient Yes / No 1 pt
  18. Longest turnover observed, from patient leaving to room ready (minutes) Number
  19. Turnover of rooms between patients Rating
    • Complete every time observed 5 pts
    • Steps missed occasionally 3 pts
    • Paper changed only, surfaces not disinfected 1 pt

5. Privacy 14 items

  1. The exam room door closes fully and latches Yes / No 1 pt
  2. Doors were closed on every occupied room seen from the corridor Yes / No 1 pt
  3. A curtain or screen shields the exam table from view when the door opens Yes / No 1 pt
  4. Window blinds are closed or the glass is frosted Yes / No 1 pt
  5. Employees observed knocked and waited before entering an occupied room Yes / No 1 pt
  6. Patients are left alone to change into a gown Yes / No 1 pt
  7. A conversation at normal volume in the room could not be followed from the hallway with the door closed Yes / No 1 pt
  8. The screen was locked in each room where a patient was waiting alone Yes / No 1 pt
  9. No other patient's labels, printouts or notes were visible in the rooms inspected Yes / No 1 pt
  10. Chart holders or schedules outside the door show no patient name facing the hallway Yes / No 1 pt
  11. Room status flags or lights do not indicate a diagnosis or the reason for the visit Yes / No 1 pt
  12. A notice in the room tells patients they may ask for a chaperone Yes / No 1 pt
  13. Patient weight taken at a hallway scale is not said aloud Yes / No 1 pt
  14. Privacy of patients in exam rooms Rating
    • Protected in every room observed 5 pts
    • One lapse observed 3 pts
    • Repeated lapses observed 1 pt

6. Stocking 23 items

  1. A stock list with par quantities is posted inside a cabinet in each room Yes / No 1 pt
  2. Two rooms compared had the same items in the same drawers Yes / No 1 pt
  3. Drawers and cabinets are labeled with their contents Yes / No 1 pt
  4. None of 10 items sampled in the rooms was below its par quantity Yes / No 1 pt
  5. A named employee is assigned to restock each room Yes / No 1 pt
  6. The restocking checklist is signed for each of the last 5 clinic days Yes / No 1 pt
  7. Rooms are restocked at the end of the day, not during patient visits Yes / No 1 pt
  8. Newer stock is placed behind older stock in the drawers Yes / No 1 pt
  9. The monthly expiry check of exam room stock is recorded Yes / No 1 pt
  10. Date of the last recorded expiry check of exam room stock Date
  11. No cardboard shipping boxes are in exam rooms Yes / No 1 pt
  12. No drawer or cabinet sampled held more than the par quantity of an item Yes / No 1 pt
  13. No sample medications are kept in exam rooms Yes / No 1 pt
  14. No prescription pads or prescription paper are left in exam rooms Yes / No 1 pt
  15. Drawers holding needles or syringes are locked in rooms where patients wait alone Yes / No 1 pt
  16. Patient education handouts in the rooms are the current version Yes / No 1 pt
  17. Clean supplies are not stored on the floor Yes / No 1 pt
  18. The restocking closet or cart serving the rooms holds every item on the par list Yes / No 1 pt
  19. Clinical employees asked reported no item running out in a room during the last week Yes / No 1 pt
  20. Items found below par in the rooms inspected Number
  21. Name of the employee responsible for exam room stocking Short text
  22. Overall readiness of exam rooms Rating
    • Ready for patients in every room 5 pts
    • Ready with minor gaps 3 pts
    • Not ready in one or more rooms 1 pt
  23. Corrective actions required Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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