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