Healthcare Dew Point Report

HEALTHCARE DEW POINT REPORT

Patient & Facility Identification

Patient Name:   Date of Birth:

Male   Female   Other   Decline to State

Insurance / Subscriber

Medical History (Relevant to Environmental Conditions)

Measurement Details

Facility Location:   Area/Room ID:

Measurement Date:   Time:

Ambient Temperature (dry bulb):   Relative Humidity:

Calculated Dew Point:   Measurement Method:

Acceptable Ranges & Observations

Facility Target Dew Point Range: From to

Within Acceptable Limits: Yes   No

Data Handling, Confidentiality, & Authorization

This report contains clinical and environmental information that may constitute protected health information. Access to this report is restricted to personnel with a need to know and will be handled in accordance with facility privacy and data security policies. By signing below, the patient or authorized representative acknowledges receipt of this report and authorizes its inclusion in the medical record for continuity of care.

Acknowledged: I acknowledge the privacy and handling statement above.

Authorization Expiration Date:

Certification

I certify that the measurements reported above were performed in accordance with the facility Environmental Monitoring Protocol, that instruments used were in proper working order and calibrated as indicated, and that the information provided is true and accurate to the best of my knowledge. Any deviations or corrective actions have been documented in this report. I understand that falsification of environmental monitoring records may result in administrative or clinical review.

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