Sample OR/Procedure Room Cleaning Checklist

In addition to documenting the cleaning of its general areas, Lakeland (Fla.) Surgical & Diagnostic Center also ensures cleaning of its ORs and procedure rooms are properly documented.



The ASC requires the cleaner, whether it be a cleaning crew or support staff, to fill out and initial a checklist form indicating which room is cleaned and when all of 10 cleaning tasks are completed. These tasks includes removal of all trash and waste; cleaning and dusting of walls, doors, x-ray view boxes and fire extinguishers; moving all equipment to ensure thorough sweeping and mopping; and cleaning of kick buckets and replacing of red bag liners.


The surgery center also has a member of its OR staff inspect the areas in 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 cleaning and disinfecting was performed by those involved in the cleaning process.


If the staff observes any deficiencies, the form is then sent to the cleaning company or provided to the department manager to follow-up with those individuals involved in the deficient cleaning.


To download a sample copy of the terminal cleaning checklist you can adapt for use in your ASC, click here (doc). To download a Spanish version of this checklist, click here (doc).


Learn more about Lakeland Surgical & Diagnostic Center.


Download other sample forms for adaptation and use in your ASC:


- Sample Medication Reconciliation Form


- Sample ASC Adult PONV/PDNV Policy


- Sample ASC Time-Out Policy and Procedure

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