Hand Hygiene Audit Checklist

• Site conducted

  Select

• Facility

• Location
  Address

• Name of Auditor

• Date of Audit

  Date

Hand Hygiene Audit

• Is the patient on Isolation Precautions?

  Yes

  No

  N/A

• Is notification visible outside of room?

  Yes

  No

  N/A
Healthcare Worker

• Select healthcare worker category.

  Select Nurse Medical Doctor Lab Radiology CNA Transporter Other

  • Nurse
  • Medical Doctor
  • Lab
  • Radiology
  • CNA
  • Transporter
  • Other

• 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