Hand Hygiene Monthly Audit (Ward)

• Document No.

• Audit Title Hand Hygiene

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Healthcare Worker 1

• Which Healthcare Worker?

  Select HCA RN Surgeon ODP

  • HCA
  • RN
  • Surgeon
  • ODP

• Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other

  Yes

  No

  N/A

• What method?

  Gel

  Wash

• Did they spend 15-20 seconds washing their hands?<br>

  Yes

  No

  N/A

• Entry or Exit?

  Entry

  Exit

• Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

  Yes

  No

  N/A

Healthcare Worker 2

• Which Healthcare Worker?

  Select HCA RN Surgeon ODP

  • HCA
  • RN
  • Surgeon
  • ODP

• Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other

  Yes

  No

  N/A

• What method?

  Gel

  Wash

• Did they spend 15-20 seconds washing their hands?<br>

  Yes

  No

  N/A

• Entry or Exit?

  Entry

  Exit

• Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

  Yes

  No

  N/A

Healthcare Worker 3

• Which Healthcare Worker?

  Select HCA RN Surgeon ODP

  • HCA
  • RN
  • Surgeon
  • ODP

• Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other

  Yes

  No

  N/A

• What method?

  Gel

  Wash

• Did they spend 15-20 seconds washing their hands?<br>

  Yes

  No

  N/A

• Entry or Exit?

  Entry

  Exit

• Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

  Yes

  No

  N/A

Healthcare Worker 4

• Which Healthcare Worker?

  Select HCA RN Surgeon ODP

  • HCA
  • RN
  • Surgeon
  • ODP

• Did they perform hand hygiene? (If no, please provide the reason: Hands full, Frequent entry/exit, <br>Dispencer empty, Improper glove use, or Other

  Yes

  No

  N/A

• What method?

  Gel

  Wash

• Did they spend 15-20 seconds washing their hands?<br>

  Yes

  No

  N/A

• Entry or Exit?

  Entry

  Exit

• Do fingernails meet Hand Hygiene Policy? ( No artificial nails, no overlays, no chipped fingernail polish. Nails 1/4 inch or less in length?)

  Yes

  No

  N/A

Confirm Date and Time and Signature

• Date and Time Completed

  Date

• By entering name, this acts as an electronic signature.

  Sign