Healthcare Environmental Monitoring Form

HEALTHCARE ENVIRONMENTAL MONITORING FORM

Facility and Patient Information

Location/Area being monitored:

Patient Name:    Medical Record #:

Patient DOB:    Gender:

Patient Phone:    Room/Bed:

Insurance / Billing Information (If applicable)

Policy Number:    Group Number:

Medical / Clinical Context

Environmental Monitoring Details

Monitoring Date:    Start Time:    End Time:

Performed By (Name):    Title:

Contact Phone:    Department Contact Email:

Patient Room    Operating Room    Isolation Room    Laboratory

Waiting Area    Pharmacy/Service Area    Other:

Parameters and Samples Collected

Tests Performed (check all that apply)

Viable Plate Counts    Particle Count    Humidity    Temperature

Airflow/ACH    Water Culture    Surface Swabs

Sample Records

Sample ID:    Type:    Location:

Sample Time:    Method:    Result:    Units:

Acceptable Range:    Action Required:

Sample ID:    Type:    Location:

Sample Time:    Method:    Result:    Units:

Acceptable Range:    Action Required:

Sample ID:    Type:    Location:

Sample Time:    Method:    Result:    Units:

Acceptable Range:    Action Required:

Observations, Results Summary and Corrective Action

Responsible Person:    Due Date for Completion:

Attachments and Laboratory Information

Photos Attached:    Laboratory Report Attached:    Chain of Custody Attached:

Privacy, Compliance and Certification

The information collected on this form is recorded to document environmental conditions in the course of healthcare operations and to support infection control measures. Data that identifies a patient is protected health information and will be handled in accordance with applicable privacy policies. Access to these records is restricted to personnel with a legitimate need for infection control, clinical care, environmental services, or regulatory compliance.

I acknowledge that the environmental monitoring results will be used for clinical risk assessment and facility corrective actions. This form serves as an official record and may be used for internal reviews and regulatory reporting where required by law or facility policy.

I acknowledge the above privacy and compliance statement and certify that the information recorded on this form is true and accurate to the best of my knowledge.

Inspector / Recorder Certification

I certify that samples were collected, handled, and recorded in accordance with the facility's environmental monitoring protocols and standard sampling procedures. Any deviations from protocol are documented in the Observations / Field Notes section above.

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