Caregiver Masking and HH Compliance

• Conducted on

  Date

• Unit

  Select

Room Observations
• Room number
  Address

• Is the room an isolation room?

  Yes

  No

  Unsure

• Is any precautions signage posted?

  Select Contact Droplet/Contact Droplet/Contact Plus Airborne Protective Isolation

  • Contact
  • Droplet/Contact
  • Droplet/Contact Plus
  • Airborne
  • Protective Isolation

• How many patients are assigned to the room?

  1

  2

  3

  Unsure
Caregiver Observations

• Was the caregiver entering the room or leaving the room?

  Entering

  Leaving

  Unsure

  Other

• Did they clean their hands prior to entering the room?

  Yes

  No

  Unsure

• Did they clean their hands after entering the room but before touching the patient or environment?

  Yes

  No

  Unsure

• Were they masked in the hall prior to entering the patient room?

  Yes

  No

  Unsure

• Did they don their mask upon entering the room?

  Yes

  No

  Unsure

• Did the caregiver clean their hands immediately after leaving the room?

  Yes

  No

  Unsure

• Did you observe the caregiver clean their hands prior to touching anything in the healthcare environment (i.e. nursing desk)?

  Yes

  No

  Unsure

• Was the caregiver masked upon leaving the room?

  Yes

  No

  Unsure

• Did you observe the caregiver don their mask at any point outside the patient room?

  Yes

  No

  Unsure

Comments

• Any other comments or notes to make?