Hand Hygiene Audit Checklist

• Facility

• Location
  Address

• Name of Auditor

• Date of Audit

  Date

Hand Hygiene Audit

• List the healthcare workers to be observed by tapping ADD HEALTHCARE WORKER.

Healthcare Worker

• Name of Healthcare Worker (optional)

• Select healthcare worker category.

  Nurse/ Midwife

  Auxiliary

  Medical Doctor

  Other Healthcare Worker

• Please specify.

• Ward/ Unit/ Department

The Five Moments of Hand Hygiene

• Before patient contact

  Yes

  No

  N/A

• Before an aseptic prodecure

  Yes

  No

  N/A

• After body fluid exposure

  Yes

  No

  N/A

• After patient contact

  Yes

  No

  N/A

• After contact with patient surroundings

  Yes

  No

  N/A

Completion

• Overall Recommendations

• Full Name and Signature of Auditor

  Sign