Free worksheets

Four one-page worksheets for outpatient rounds.

For surgery centers, dialysis clinics and medical and dental offices. Print them, copy them, hand them to whoever walks the building. Each one notes the rule behind every check, so you know why it's on the list.

Free, no sign-up. Just click and print.

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Print them, copy them, use them.

Written for outpatient sites. Most of it works for any building that gets inspected. Items for Medicare-certified surgery centers and dialysis clinics are marked; the rest apply to every office.

01 · Monthly round

12-item monthly clinic facility checklist

One walk-through a month, marked Pass, Fail or N/A, with room for notes and a sign-off.

  • Exits, exit signs and emergency lighting
  • Fire extinguishers, fire alarm, sprinklers and fire doors
  • Electrical panels and cords, eyewash stations, gas cylinders
  • Chemical labels and safety data sheets, building condition
Download the PDF 1 page · letter
02 · Before a visit

10-point physical environment readiness checklist

Run it a month before a survey, accreditation visit, fire marshal inspection or OSHA visit. Each point asks: could you hand the record over today?

  • Extinguisher, emergency lighting, fire alarm and sprinkler records
  • Fire drills and the emergency plan, generator tests
  • Eyewash and chemical records, equipment maintenance
  • Open deficiencies and how they were closed
Download the PDF 1 page · letter
03 · Follow-through

Deficiency tracking log

One line for every failed check, from any round or contractor report, until someone writes the date it was fixed and who checked the fix.

  • Where it was found, what failed, who found it
  • The fix needed, who owns it and when it's due
  • Date fixed and who checked the fix
Download the PDF 1 page · letter, landscape
04 · Know what's asked

6 facility checks surveyors ask for first

The records the building part of a visit usually starts with: what they ask to see, how often it's due, and where the requirement comes from.

  • Fire extinguishers; fire alarm and sprinkler testing
  • Emergency lighting and exit signs; generator testing
  • Fire drills and the emergency plan; eyewash and chemicals
Download the PDF 1 page · letter
RATHER NOT PRINT IT?

Send us your own checklist. We'll set it up.

Email us a photo or scan of a checklist you use today, or one of these. We'll build it into a free FacilityRounds account with your own buildings, so your team can walk it on an iPad or phone.

Email us a checklist

General guidance, not legal advice. What applies to you depends on your state, building, accreditor and the code editions your inspectors enforce; CMS applies the 2012 editions of NFPA 101 and NFPA 99.

THE SAME ROUNDS, ON THE RECORD

Paper works until someone asks for it.

FacilityRounds keeps these checks as dated records that lock when they're done. A failed item stays open until it's fixed, and the history exports to Excel or PDF in a click. Try the live demo with your email, or start free with one building, no credit card.