MONTH/YR:

BED NUMBER:
UNIT ROOM CHECKLIST AND DAILY PATIENT CARE EQUIPMENT
AVAILABILITY, CLEANING
DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
PAGE 1
SHIFT E N E N E N E N E N E N E N E N E N E N E N E N E N E N E N E N
ER BED
CARDIAC MONITOR
CTG MACHINE
ENT DIAGNOSTIC
VACUUM REGULATOR
WELCHALLYN THERMOMETER
INFUSION PUMP
IV STAND
ADULT
STETHOSCOPE PEDIA
OXYGEN HUMIDIFIER
SUCTION LINER & TUBING
REGULAR MASK ( 1 BOX )
UNDER PADS ( 10 PCS )
SUCTION CATHETERS SIZE (8,13) 2PCS
S
CLEAN GLOVES M
( 1 BOX EACH ) L
6
STERILE GLOVES 7
( 2 PCS EACH ) 8
NEBULIZATION ADULT
MASK (1PC EACH) PEDIATRIC
NASAL CANNULA ADULT
( 1 PC EACH ) PEDIATRIC
FACE MASK ADULT
( 1PC EACH) PEDIATIC

NOTE: Put a ( /) mark sign if the said ITEMS are available.

LEGEND FOR USED EQUIPMENTS:
If one item is not available, kindly put “NA” next to the item.
AC- AVAILABLE & CLEANED
ANC- AVAILABLE; NOT CLEANED
NA- NOT AVAILABLE
KINDLY REPORT TO THE CHARGE NURSE IF CERTAIN ITEM/S NOT AVAILABLE ASAP. ALSO, PLEASE MAKE SURE ITEMS ARE COMPLETE & VALID.
FOR STRICT COMPLIANCE. Thank you!
 MONTH/YR:
BED NUMBER:
UNIT ROOM CHECKLIST AND DAILY PATIENT CARE EQUIPMENT
AVAILABILITY, CLEANING
PAGE 2 DATE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
SHIFT E N E N E N E N E N E N E N E N E N E N E N E N E N E N E N E N
ELECTRODES ( 10 PCS )
10CC
SYRINGES 5CC
( 3 PCS EACH )
3CC
NEEDLES G25 “ SHORT “
( 3 PCS EACH ) G25 “ LONG “
G18
G20
IV CANNULAS
( 3 PCS EACH ) G22
G24
G26
RED
VACUTAINER VIOLET
( 5 PCS EACH )
BLUE
GREEN
TURNIQUET
KY GEL ( 1 TUBE )
ALCOHOL SWABS ( 30 PCS )
SWAN LOCK ( 5 PCS )
BAND AID ( 20 PCS )
PLASTER
GAUZE 5X5 ( 1 PACK )
TOUNGUE DEPRESSOR ( 10 PCS )
AMNICATOR STICK ( 5 PCS )
SHARP CONTAINER
SCISSORS
STAFF ID & SIGNATURE

NOTE: Put a ( /) mark sign if the said ITEMS are available.

LEGEND FOR USED EQUIPMENTS:
If one item is not available, kindly put “NA” next to the item.
AC- AVAILABLE & CLEANED
ANC- AVAILABLE; NOT CLEANED
KINDLY REPORT TO THE CHARGE NURSE IF CERTAIN ITEM/S NOT AVAILABLE ASAP. ALSO, PLEASE MAKE SURE ITEMS ARE COMPLETE & VALID.
NA- NOT AVAILABLE
FOR STRICT COMPLIANCE. Thank you!
 MONTH/YR:
BED NUMBER:
UNIT ROOM CHECKLIST AND DAILY PATIENT CARE EQUIPMENT
AVAILABILITY, CLEANING
PAGE 1 DATE 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
SHIFT E N E N E N E N E N E N E N E N E N E N E N E N E N E N E N
ER BED
CARDIAC MONITOR
CTG MACHINE
ENT DIAGNOSTIC
VACUUM REGULATOR
WELCHALLYN THERMOMETER
INFUSION PUMP
IV STAND
ADULT
STETHOSCOPE PEDIA
OXYGEN HUMIDIFIER
SUCTION LINER & TUBING
REGULAR MASK ( 1 BOX )
UNDER PADS ( 10 PCS )
SUCTION CATHETERS SIZE (8,13) 2PCS
S
CLEAN GLOVES M
( 1 BOX EACH ) L
6
STERILE GLOVES 7
( 2 PCS EACH ) 8
NEBULIZATION ADULT
MASK (1PC EACH) PEDIATRIC
NASAL CANNULA ADULT
( 1 PC EACH ) PEDIATRIC
FACE MASK ADULT
( 1PC EACH) PEDIATIC

NOTE: Put a ( /) mark sign if the said ITEMS are available. LEGEND FOR USED EQUIPMENTS:
If one item is not available, kindly put “NA” next to the item. AC- AVAILABLE & CLEANED
ANC- AVAILABLE; NOT CLEANED
KINDLY REPORT TO THE CHARGE NURSE IF CERTAIN ITEM/S NOT AVAILABLE ASAP. ALSO, PLEASE MAKE SURE ITEMS ARE COMPLETE & VALID. NA- NOT AVAILABLE
FOR STRICT COMPLIANCE. Thank you!
 MONTH/YR:
BED NUMBER:
UNIT ROOM CHECKLIST AND DAILY PATIENT CARE EQUIPMENT
AVAILABILITY, CLEANING
PAGE 2 DATE 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
SHIFT E N E N E N E N E N E N E N E N E N E N E N E N E N E N E N
ELECTRODES ( 10 PCS )
10CC
SYRINGES 5CC
( 3 PCS EACH )
3CC
NEEDLES G25 “ SHORT “
( 3 PCS EACH ) G25 “ LONG “
G18
G20
IV CANNULAS
( 3 PCS EACH ) G22
G24
G26
RED
VACUTAINER VIOLET
( 5 PCS EACH )
BLUE
GREEN
TURNIQUET
KY GEL ( 1 TUBE )
ALCOHOL SWABS ( 30 PCS )
SWAN LOCK ( 5 PCS )
BAND AID ( 20 PCS )
PLASTER
GAUZE 5X5 ( 1 PACK )
TOUNGUE DEPRESSOR ( 10 PCS )
AMNICATOR STICK ( 5 PCS )
SHARP CONTAINER
SCISSORS
STAFF ID & SIGNATURE

NOTE: Put a ( /) mark sign if the said ITEMS are available.

LEGEND FOR USED EQUIPMENTS:
If one item is not available, kindly put “NA” next to the item.
AC- AVAILABLE & CLEANED
ANC- AVAILABLE; NOT CLEANED
KINDLY REPORT TO THE CHARGE NURSE IF CERTAIN ITEM/S NOT AVAILABLE ASAP. ALSO, PLEASE MAKE SURE ITEMS ARE COMPLETE & VALID.
NA- NOT AVAILABLE
FOR STRICT COMPLIANCE. Thank you!