Printable hospital template
Hospital shared-device custody log
Record which staff member has a hospital device, its condition and the return acknowledgement, with account access and pending work separately accountable.
- Written by
- RizCare
- Published
- Last reviewed
RizCare's suggested worksheet. Adapt to your hospital. https://riz.care/library/templates/clinic-shared-device-checkout-log
For staff responsible for shared hospital devices.
A tablet moves from reception to the consulting room. By afternoon, nobody knows who last had it or whether it needs charging. Record custody when the device moves rather than trying to reconstruct the route at closing time.
Physical possession and permission to read records are separate matters. A signed custody row does not grant an account, reveal a password or authorise a device reset.
Print this page or save it as a PDF from your browser. The print layout contains only the blank worksheet and its completion note. Fill it in within your hospital.
Practice: ____________________ Prepared by: ____________________ Date: ______________
| Asset / issued | Accepted by | Condition / accessories | Return expected | Returned / checked |
|---|---|---|---|---|
| Blank entry | ||||
| Blank entry | ||||
| Blank entry | ||||
| Blank entry | ||||
| Blank entry |
Keep completed copies with the staff authorised to use them.
How to use it
Check the device being handed over
Use the hospital's asset reference and note visible damage, missing accessories or a reported problem. Confirm the receiving staff member and the agreed return point. If a device has saved work awaiting attention, refer that work to its owner through the normal system process. Keep patient details out of this equipment log.
Use individual access
The outgoing user follows the supported locking or sign-out procedure before another person uses the device. The incoming user works through their own authorised access. Do not write passwords, recovery secrets or unlock codes on the custody sheet. If access fails, raise that issue separately while keeping the equipment's physical location known.
Check the return
Record the actual return time and accepting person. Check the accessories and any new damage with the returning colleague. A missing device, suspected loss or security concern needs the hospital's incident procedure. Do not clear browser storage, reinstall the app or wipe a device as part of a routine handover; that can affect work held on it.
What each field means
- Asset reference
- Choose the label used in the equipment inventory. A description such as black tablet is inadequate when two devices look alike.
- Condition and pending action
- Record an observable fault or a support reference. Keep the explanation limited to equipment and administrative work rather than patient content.
- Return acknowledgement
- The person accepting the return signs after checking the device. A planned return time remains a plan until the equipment is actually received.
Completed fictional example
TAB-02 is a fictional asset. Its custody history says nothing about which records are available on the device.
| Asset / issued | Accepted by | Condition / accessories | Return expected | Returned / checked |
|---|---|---|---|---|
| TAB-02 / 08:10 | Staff A | Case and charger present | 14:00 | 13:55 / Staff B |
Related resources
Sources and review
The worksheet design and examples are RizCare's recommendations. The sources below support the background discussion; they do not endorse this form.
- Workflow Assessment for Health IT Toolkit (Agency for Healthcare Research and Quality). Read 9 September 2026.