OT observation room audit checklist

Room Environment

Cleanliness of room

Temperature and ventilation

Lighting levels

Noise levels

Presence of any odors or unpleasant smells

Accessibility of emergency exits

Organization and tidiness of equipment and supplies

Comfort of furniture for both therapists and patients

Presence of any potential hazards or obstacles in the room

Adequacy of privacy measures for patient confidentiality

Equipment

Functional status of equipment (e.g. therapy tables, exercise equipment)

Safety features on equipment (e.g. railings, straps)

Availability of necessary equipment for therapy sessions

Cleanliness of equipment

Proper storage of equipment when not in use

Condition of equipment (e.g. any broken or damaged parts)

Accessibility of equipment for patients with mobility limitations

Calibration of equipment (if applicable)

Functionality of electrical equipment (e.g. ultrasound machines, electrical stimulation devices)

Availability of different sizes or variations of equipment to accommodate different patient needs

Proper maintenance schedule for equipment

Compliance with infection control protocols for equipment cleaning

Emergency procedures in place for equipment malfunctions

Accessibility of emergency shut-off switches on equipment

Training provided to therapists on proper use of equipment

Therapist Practices

Therapist attire and personal hygiene

Use of proper body mechanics during therapy sessions

Clear communication with patients

Use of appropriate therapy techniques

Adherence to infection control protocols

Properly addressing patient concerns or complaints

Regular assessment and reassessment of patient progress

Providing patient education and instructions clearly

Collaborating with other healthcare professionals for comprehensive patient care

Ensuring patient confidentiality and privacy

Seeking supervision or guidance when necessary

Monitoring and managing time effectively during therapy sessions

Patient Safety

Patient positioning during therapy sessions

Use of appropriate safety measures (e.g. gait belts, transfer boards)

Monitoring patient response to therapy interventions

Following infection control protocols

Ensuring proper use of assistive devices by the patient

Adequate supervision of patients with mobility limitations

Communication with other healthcare providers regarding any safety concerns

Regular assessment of the patient's fall risk and implementation of appropriate precautions

Emergency preparedness training for staff in case of patient injury or medical emergency

Documentation

Completion of therapy notes in a timely manner

Accuracy of documentation

Compliance with HIPAA regulations

Communication of patient progress with other healthcare team members

Use of appropriate terminology and language in documentation

Inclusion of patient goals and progress in therapy notes

Consistency in documenting patient assessments and interventions

Proper formatting and organization of therapy notes

Documentation of any changes in patient condition or treatment plan

Adherence to facility's documentation policies and procedures

Review and signature of documentation by appropriate personnel

Overall Observation

Overall impression of therapist-patient interactions

Assessment of therapy sessions for effectiveness

Identification of areas for improvement

Recommendations for continued quality improvement.