Title Page
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Document No.
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Audit Title Hand Hygiene
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Healthcare Worker 1
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Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
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Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
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What method?
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Did they spend 15-20 seconds washing their hands?<br>
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Entry or Exit?
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Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 2
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Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
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Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
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What method?
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Did they spend 15-20 seconds washing their hands?<br>
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Entry or Exit?
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Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 3
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Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 4
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Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 5
-
Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 6
-
Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays,no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 7
-
Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 8
-
Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlay, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 9
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Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Healthcare Worker 10
-
Which Healthcare Worker?
- MD
- RN
- ED Tech
- Rad Tech
- Lab Tech
- PAS
- Dietary Tech
-
Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other
-
What method?
-
Did they spend 15-20 seconds washing their hands?<br>
-
Entry or Exit?
-
Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)
Confirm Date and Time and Signature
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Date and Time Completed
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By entering name, this acts as an electronic signature.
