Operating Room Terminal Cleaning Checklist
Use this form to document the final cleaning of an operating room, confirm completion of required terminal-cleaning steps, and record any issues before the room is released for the next case.
Room and Cleaning Session Details
Operating Room ID / Location
*
Date of Cleaning
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cleaning Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Cleaning End Time
*
Hour Minutes
AM
PM
AM/PM Option
Shift
*
Please Select
Day
Evening
Night
Room Status Before Cleaning
*
Please Select
In Use
Vacated
Ready for Cleaning
Other
Procedure Type / Case Reference
Cleaning Staff and Verification
Cleaning staff member name
*
First Name
Middle Name
Last Name
Supervisor or verifier name
*
First Name
Middle Name
Last Name
Final sign-off / initials
*
Cleaning Materials and Checklist
Cleaning products used
*
Disinfectant wipes
Hospital-grade disinfectant spray
Detergent cleaner
Mop solution
Surface disinfectant
Other
High-touch surfaces
*
Rows
Completed
Not complete
Not applicable
Bed rails
1
2
3
Overbed table
4
5
6
Light switches
7
8
9
Call buttons
10
11
12
Door handles
13
14
15
Operating room surfaces
*
Rows
Completed
Not complete
Not applicable
Operating table surface
16
17
18
Procedure lights
19
20
21
Counters and shelves
22
23
24
Equipment surfaces
25
26
27
Control panels
28
29
30
Room cleaning actions
*
Rows
Completed
Not complete
Not applicable
Floor cleaned
31
32
33
Walls wiped as needed
34
35
36
Waste removed
37
38
39
Used linen removed
40
41
42
Final wipe-down completed
43
44
45
Area-specific final wipe-down
Rows
Completed
Not complete
Not applicable
Anesthesia area
46
47
48
Surgical field area
49
50
51
Monitor area
52
53
54
Patient transfer area
55
56
57
Other assigned area
58
59
60
Additional cleaning notes
Exceptions and Outcome
Missed or incomplete items
None
Bed rails
Call button
Overbed table
Floor corners
Other
Issues or observations
Final completion status
*
Ready for next case
Requires follow-up cleaning
Submit Checklist
Submit Checklist
Should be Empty: