Information
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Document No.
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Audit Title
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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
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Unit:
- Med-Surg
- ARU
- Tele
- OB-Peds
- ICU
- ED
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Room number:
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Observation of identified precautions :
- Gloves observed
- Gown observed
- Mask observed
- Hand Hygiene observed
- Proper isolation precautions not observed
- Did not observe precations at this time
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Type of Isolation Implemented:
- Airborne (Yellow)
- Airborne Contact and immune sign (Purple)
- Contact (Orange)
- Contact GI and stop sign (green)
- Droplet (light blue)
- Enhanced Droplet (Pink)
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Correct Sign/s on the door?
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Charting Completed:
- Order in Chart
- Flowsheet Documentation
- Education Implemented
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If gaps in isolation precautions found, staff contacted:
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Additional Comments:
