Hand Hygiene Observation Unit: Date: Tool Observer Name: DIRECTIONS - If you believe you observed hand hygiene’ or are unsure, please confirm with staff privately; remind if applicable. (Some staff members ‘no carry their own hand sanitizer. Remember to observe process in its entirety). full’ ‘hands FORM UPDATES: 'Nursing’ is now (RN)’, Nursing (CNA)’ and Nursing (Tech) are now (Nursing)’, (CNA)’, (Medical)’, ‘Nursing ‘Students’ ‘Student ‘Student ‘Student The section is alphabetized and Lab’ (personnel) has been added. ‘Student ‘OTHER’ ‘Cath Surgeons and Medical Providers are divided by specialty record by #. – Role of Observed Person Observed Behavior Surgeon Prov (Medical) Circle OTHER use # – 1 Admitting Cardiac Cardiology ONE Cath Lab General Emergency Clergy Neuro Fam Practice Engineering water OB/Gyn GI of EVS Orthopedic Internal Med feedback Imaging and remind Plastics Nephrology Lab name Urology Neurology ask Nutr Services soap – etc. Other Oncology Pharmacy member, w/ unsure PT-OT-ST Unknown Pediatrics record Resp Therapy – Psychiatry sanitizer staff (Unknown) hygiene SS/Case Mgmt (Hospitalist) (Anesthesia) (PA/NP) (CNM) (Resident/Fellow) Radiology view/ (Nursing) (CNA) (Medical) (Other) (RN) (CNA) (Tech) Transport washing response, Other hand Unknown hand Unknown Nursing Nursing Nursing Used No Hand Provider Provider Provider Provider Provider Provider Blocked Comments observed Student Student Student Student given, 1 IN OUT 2 IN OUT 3 IN OUT 4 IN OUT 5 IN OUT 6 IN OUT 7 IN OUT 8 IN OUT 9 IN OUT 10 IN OUT 11 IN OUT 12 IN OUT 13 IN OUT 14 IN OUT 15 IN OUT 16 IN OUT Revised 4-10-12
Unit: Date: Hand Hygiene Observation Tool Observer Name: DIRECTIONS - If you believe you observed ‘no hand hygiene’ or are unsure, please confirm with staff privately; remind if applicable. (Some staff members carry their own hand sanitizer. Remember to observe ‘hands full’ process in its entirety). FORM UPDATES: 'Nursing’ is now ‘Nursing (RN)’, Nursing (CNA)’ and Nursing (Tech) ‘Students’ are now ‘Student (Nursing)’, ‘Student (CNA)’, ‘Student (Medical)’, ‘Student The ‘OTHER’ section is alphabetized and ‘Cath Lab’ (personnel) has been added. Surgeons and Medical Providers are divided by specialty – record by #. Role of Observed Person Observed Behavior Nursing (RN) Nursing (CNA) Nursing (Tech) Surgeon Cardiac General Neuro OB/Gyn Orthopedic Plastics Urology Other Unknown Prov (Medical) Cardiology Emergency Fam Practice GI Internal Med Nephrology Neurology Oncology Pediatrics Psychiatry Radiology Other Unknown Provider (Hospitalist) Provider (Anesthesia) Provider (PA/NP) Provider (CNM) Provider (Resident/Fellow) Provider (Unknown) Student (Nursing) Student (CNA) Student (Medical) Student (Other) OTHER – use # 1 Admitting Cath Lab Clergy Engineering EVS Imaging Lab Nutr Services Pharmacy PT-OT-ST Resp Therapy SS/Case Mgmt Transport Unknown Circle ONE Blocked view/ unsure Used hand sanitizer Hand washing w/ soap and water No hand hygiene – ask remind Comments – record name of observed staff member, feedback given, response, etc. 1 IN OUT 2 IN OUT 3 IN OUT 4 IN OUT 5 IN OUT 6 IN OUT 7 IN OUT 8 IN OUT 9 IN OUT 10 IN OUT 11 IN OUT 12 IN OUT 13 IN OUT 14 IN OUT 15 IN OUT 16 IN OUT Revised 4-10-12
2017%20MDPH%20CRE%20Toolkit_Ver%201%200.docx