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Administrative (Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin
Hospitals and Clinics Authority as integrated effective July 1, 2015, including the legacy
operations and staff of University of Wisconsin Hospital and Clinics and University of
Wisconsin Medical Foundation.
Policy Title: Stocking and Cleaning of Food in Patient Unit Kitchens and
Policy Number: 3.16
Effective Date: November 20, 2017
Chapter: Culinary Services
A. To establish guidelines for providing patient units with appropriate food and supplies for patient
requests and meal supplements.
B. To ensure safe handling, proper storage and disposal of foods prepared or stocked by the hospital
and food brought from home for patient consumption during the hospital stay that are located in
the patient care unit kitchens and family lounges.
C. To provide guidelines for division of duties related to the cleaning of all patient care unit kitchens
to ensure compliance with all sanitation standards and code requirements.
A. Stock items including amounts (par levels) will be determined by Culinary and Clinical Nutrition
Services. Amounts will be reviewed periodically by the nurse manager to evaluate if the par
levels are adequate to meet patient needs.
B. Family members and friends may bring food to a patient unless ordered otherwise by the patient's
physician. All foods brought into the hospital for the patient by a family member or friend will be
evaluated by nursing in order to comply with diet order prescribed by the patient's physician.
Perishable food intended for patient consumption (whether from internal or external sources) will
be held in the refrigerator located on patient care units, labeled according to proper food storage
procedures. Nursing staff are responsible for appropriate dating of items and all hospital staff
members are responsible for disposal of outdated items.
C. Cleaning of the patient unit kitchens and family lounges are completed through coordination of
activities between Environmental Services and Culinary Services. These departments work
together to ensure a safe, clean, sanitary, code compliant environment for the storage and
preparation of food products.
A. Stocking Procedures:
1. Par levels will be determined for each unit and stock will be delivered to each patient care
unit by Culinary Services staff. Stock will be added to the established par level according to
the stock sheet posted in the patient unit kitchen. Excess stock will be returned to the main
2. Stock will be rotated so the "oldest" items will be used first (FIFO). Stock with expired dates
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will be discarded. Items that are partially used or open containers will be discarded.
3. Food products not stocked by Culinary Services and found in the patient care unit kitchens
will be discarded if they are not marked with the name of the patient (or other patient
identification) and a use-by date.
4. Frozen Supplies
a. Culinary Service Employees will mark all stocked frozen products with a use-by date label
if there is no manufacturer use-by label on each individual item.
b. Use-by date will be the manufacturer’s use-by date or 3 months from the date the original
i. The Culinary Services Supervisor or lead worker will check the patient care unit
kitchen and family lounges on a timely basis to determine if supplies are being stored
properly, outdated foods are being discarded, and excess menu items are returned to
the main kitchen.
ii. Temperatures for refrigerators and freezers located on the patient units are monitored
B. Storage of Food for patients
1. Labeling of Food Prior to Storage
a. All foods brought in by family/friends for a patient must be labeled with patient
name, room number, birth date or medical record number, and a use-by date. Name
of food should also be noted on the label, unless its identity is unmistakable. The
use-by date is no more than 3 days from receipt of perishable and/or prepared food.
b. Once products are opened they need to be consumed or discarded. Products opened
and served to a patient are not to be returned to the refrigerator for storage.
c. Raw food (meat, eggs, etc) except washed fruits and vegetables shall not be stored in
patient care unit refrigerators. Raw meats and eggs may not be served.
d. All food stocked by Culinary Services will be stored in original package, clean
covered container or wrapped and bagged until service. Food is placed in the lower
half of the unit refrigerator. The only food stored in the bottom portion of the patient
care unit kitchen refrigerator will be food delivered from Culinary Services.
2. Check-in with Nursing
a. Family members and friends who wish to bring food in for a patient will report first
to the nurse's station to ensure that the patient does not have any restrictions such as
NPO, Clear liquids, or Full liquids, and that the food provided is within the
limitations of the patient's diet order. (Note: If any questions arise concerning the
appropriateness of the food, contact the clinical nutritionist or nutrition technician by
page or the diet office at 5-0202).
b. Nursing will check quality of food to ensure it is in sound condition, fresh, clean, and
safe for human consumption.
c. At all times, including while being transported or stored, food shall be protected from
d. Perishable prepared foods will be immediately labeled and refrigerated to maintain
required holding temperatures of potentially hazardous foods.
e. Ice being used to cool stored foods and food containers shall not be used for human
f. Nursing should review food handling guidelines with family members and friends
interested in bringing food to a patient.
3. Food Handling and Storage
a. Culinary Services employees will document the review of the patient care unit food
storage areas for out dated items.
b. Foods that were not consumed and served on the patient’s meal tray should not be
returned to the patient care unit kitchen and should be discarded. If more food is
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needed at a later time room service will need to be contacted.
c. Once opened, individual cartons of milk and juice should be consumed or discarded.
d. Foods stocked on the units for general patient use, such as juices, milk, pudding, and
gelatins will be dated with expiration date or manufacturer’s expiration date and
follow general food safety standards.
e. Food eaten by the patient from outside sources should be documented in the medical
record in the event that the food is not tolerated by the patient. This is important
when investigating source and reporting for food borne illness.
f. It is recommended that prepared perishable foods only be brought in for the meal in
which they are to be eaten. When quantity is for more than one meal, a serving
should be portioned in the patient care unit kitchen and the remainder should be
properly labeled per policy.
C. Assignment of Cleaning Responsibilities:
1. Environmental Services
a. Responsible for the cleaning of exterior of ice machines, coffee maker, toaster,
refrigerators and freezers, along with the exterior and interior of the microwaves.
b. Responsible the cleaning of the floors, dirty tray cart areas floors, sinks, countertops,
and removal of the trash and recycling.
c. Environmental Services will conduct weekly cleaning rounds to ensure compliance
with all sanitation standards and code requirements for these areas.
2. Culinary Services
a. Responsible for the cleaning of interiors of refrigerator and freezers, coffee pots,
condiment organizers, tube feeding shelf, dirty tray carts, dirty cart area walls,
interior and exterior of the cabinets
b. Culinary Services will conduct weekly cleaning rounds to ensure compliance with all
sanitation standards and code requirements for these areas.
3. Nursing staff will maintain the area between meal periods, cleaning any spills or messes as
Environmental Service’s Inspection Forms
Culinary Service’s Inspection Forms
Culinary Services Cleaning Schedules
Plant Engineering Preventative Maintenance Schedule
Health Code Requirements
Fire Code Requirements
Wisconsin Food Code
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Sr. Management Sponsor: VP, Facilities & Support Services
Author: Director, Culinary Services and Clinical Nutrition
Reviewers: Director, Environmental Services, Director, Nursing Quality, Director, Professional
Services, at The American Center
Approval committee: UW Health Administrative Policy and Procedure Committee
UW Health Chief Administrative Officer