Terminal Cleaning Checklist
OR / Procedure Room # _______
Date Cleaned _______
POLICY STATEMENT:
The OR rooms are to be terminally cleaned and check list completed by the cleaning crew or center support
staff every night. The areas cleaned will be inspected by the OR staff assigned to each room prior to the start of
cases the next day. This is to ensure the task has been completed and the appropriate level of terminal cleaning
and disinfecting has taken place by those involved in the cleaning process. This is to be used as an evaluation
tool to ensure the quality of the services we are providing and being provided and in turn providing to our
patients is acceptable.
PERFORMED BY: The cleaning company or center support staff will perform terminal cleaning. The staff
assigned to the room and general areas will check for completeness the next working day. The completed form
if any deficiencies will be faxed to XYZ Cleaning or given to department manager for follow-up with those
involved in the cleaning process.
CLEANING TASK DESCRIPTION
TASK COMPLETE
INITIALS OF
PERSON CLEANING
PASS INSPECTION
INITIALS OF
PERSON INSPECTING
1. Damp dust ceilings, AC returns/vents, fire
sprinklers, ceiling, anesthesia plugs and gas
outlets are cleaned and dusted.
2. Walls, doors, wall panels, suction wall
mounts, x-ray view boxes, gas panels, wall
outlets, and Fire Extinguisher cages are
cleaned and dusted.
3. Glass, blinds, surface counters, cabinets,
and all surfaces are cleaned, dusted, & spot
free.
4. All furniture, metal tables, OR exam table,
carts and unicels are thoroughly wiped down,
clean and dusted.
5. Spotlights are cleaned and dusted.
6. Sub-sterile room autoclave and warmer
are dusted and lint free, and the floor is
mopped, cleaned, and spot free.
7. All equipment has been moved and the
floor is thoroughly swept and mopped
8. Kick buckets and receptacles are cleaned
and red bag liners replaced.
9. Laundry and trash collection frames and
lids are wiped clean.
10. All trash and biohazardous waste has
been removed and disposed of properly.
Source: Lakeland Surgical & Diagnostic Center, Lakeland, Fla. Adapted and reprinted with permission.