Hand Hygiene Observation Tool 2010

Hand Hygiene Monitoring Form

Unit: Date: Observer Initals:

Findings/Issues:

Hand Hygiene Reinforcement

1 Y N Y N Y N Y N Y N Y N

2 Y N Y N Y N Y N Y N Y N

3 Y N Y N Y N Y N Y N Y N

4 Y N Y N Y N Y N Y N Y N

5 Y N Y N Y N Y N Y N Y N

6 Y N Y N Y N Y N Y N Y N

7 Y N Y N Y N Y N Y N Y N

8 Y N Y N Y N Y N Y N Y N

9 Y N Y N Y N Y N Y N Y N

10 Y N Y N Y N Y N Y N Y N

Did you have to intervene to avert non-compliance

Patient Contact

Environmental Contact

Hand Hygiene Before/After

If Yes - Positive Reinforcement Given

If No - Corrective Action Taken

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

MD RN LPN PCA NST NP PT RT LAB ES EGR FN TR RX CC MGT CHAP SEC XR Other/_______________

Type of Healthcare Worker: MD, RN, LPN, PCA, NST= Nursing Student, NP= Nurse Practitioner, PT, RT, LAB, ES= Environmental Services, EGR= Engineering, FN= Food and Nutrition, TR= Transport, RX= Pharmacy, CC= Care Coordinator, MGT= Management, CHAP= Chaplain, SEC= Security, XR= Rad tech, Other

Environmental Contact is defined as coming in contact with any inanimate surface including but not limited to: bed, bed rails, IV pole, walls, sink, door, counter, ventilator, TV, etc. Hand Hygiene before/after: There are two opportunities to observe HH (before and after). Each observation goes on one line.

Environmental Contact is defined as coming in contact with any inanimate surface including but not limited to: bed, bed rails, IV pole, walls, sink, door, counter, ventilator, TV, etc. Hand Hygiene before/after: There are two opportunities to observe HH (before and after). Each observation goes on one line.