Unit Name:

Room Number:

Observer Name:

Isolation Type:

Entering Isolation Room

Is appropriate signage displayed by/on the door?

Were gloves applied?

Did staff wash hands?

Were gowns applied?

Were gowns tied after being applied?

If applicable, were masks applied?

Were gloves pulled over the cuff of the gown sleeve?

Exiting the Isolation Room

Were gloves removed?

Were gowns removed?

Was appropriate Hand Hygiene used upon exiting the room?

Was the sink area clear for usage?

If a mask was required, was it removed last?

Was the equipment wiped off when staff exited the room?

If the patient was being transported, were appropriate barriers in place?

Isolation Cart

Are there adequate supplies? (Gloves, gowns, etc.)

Is disinfectant available? (CaviWipes and/or Clorox)

Are the appropriate masks for Airborne and Droplet Isolation well stocked?

Neutropenic Precautions

Is the door being kept closed?

Is the patient masked when they leave the room?

Airborne Isolation Room

Is the door being kept closed?

Are negative airflow checks being done?

Are N95 Airborne Isolation masks being consistently used?

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.