Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Context

  • 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?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.