Title Page
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Conducted on
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Auditor
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Unit
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Please specify:
Obs
- Observation
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Role of person observed
- Physician, Attending
- Physician, Resident
- Physician, Other
- Medical Student
- Nursing
- EVS
- Allied Health
- Other
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Best guess:
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Where is the observation?
- Outside patient environment
- Inside patient environment
- Getting ready to enter patient environment
- Getting ready to leave patient environment
- Other
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Describe:
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Which precautions should be applied for this patient/observation?
- None required
- Contact
- Droplet Contact
- Droplet Contact +
- Airborne
- Other
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Was HH performed prior to donning PPE?
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Was gown donned prior to gloves?
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Are gloves applied correctly and covering the sleeve cuffs?
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Are both gown ties tied behind the back?
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Was the PPE doffed in the correct order?
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Was HH performed after doffing PPE?
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Was mask applied correctly, if required?
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Was the correct eye protection applied for the observation, if required?
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Are any universal precautions required as routine practice?
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Is the person compliant with routine practices?
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Were there any sources of potential contamination (i.e. phones, pagers etc.)?
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Describe:
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If HH was performed, was the duration at least 15 seconds?
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Any HH misses?
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Names of any staff not complying with PPE or HH requirements: