Role of Observed Person Hand Hygiene Observed Behavior Measures OTHER Comments 1=Unknown with 2=Phlebotomy Rub # with 3=Social Worker LVN, Circle One Hygiene 4=Respiratory (Primary, water Resident) View/Unsure wash (RN, 5=PT/OT Cleaning & Student) PA, (Environmental Hand 6=Nutrition Observation Unknown Nurse NP, No Hand Alcohol-based Hand CNA, Provider EVS Services) Blocked Soap ENTRY 1 EXIT ENTRY 2 EXIT ENTRY 3 EXIT ENTRY 4 EXIT ENTRY 5 EXIT ENTRY 6 EXIT ENTRY 7 EXIT ENTRY 8 EXIT ENTRY 9 EXIT ENTRY 10 EXIT
Role of Observed Person Hand Hygiene Measures Observed Behavior Observation # Unknown Nurse (RN, LVN, CNA, Student) Provider (Primary, NP, PA, Resident) EVS (Environmental Services) OTHER 1=Unknown 2=Phlebotomy 3=Social Worker 4=Respiratory 5=PT/OT 6=Nutrition Circle One Blocked View/Unsure Hand Cleaning with Alcohol-based Rub Hand wash with Soap & water No Hand Hygiene Comments 1 ENTRY EXIT 2 ENTRY EXIT 3 ENTRY EXIT 4 ENTRY EXIT 5 ENTRY EXIT 6 ENTRY EXIT 7 ENTRY EXIT 8 ENTRY EXIT 9 ENTRY EXIT 10 ENTRY EXIT
HandHygieneForm.docx