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form observasi hand hygiene
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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.
