URAGA PRIMARY HOSPITAL HAND HYGIEN MONITORING AND

SURVEILLANCE FORMS
Monitoring and Surveillance Forms: Hand Hygiene monitoring form

Hand Hygiene Feedback Form

Staff Member __________________________ Date: ________________

To improve hand washing practices and to ensure that our patients are free from acquiring
infections during their hospital stay, I want share with you my recent observations

Date &
Present

Absent

Providing General Medical Services

Shift
NA

Performed hand hygiene before contact with each patient, disinfected

with either water and soap, an alcohol-based gel, or rubbing hands with
alcohol soaked cotton balls.
Patient was on transmission-based precautions; appropriate PPE donned.
Patient was on transmission-based precautions; PPE was removed and
discarded in the room, or closest waste receptacle, when exiting.
After contact with a patient, equipment that may have been in contact
with a patient (bedpan, commode, Foley bag), or the handling of
contaminated items such as linens, diapers, wash cloths, and wastes,
hand hygiene is performed immediately after service is completed.
If experienced contact with a patient’s blood or other bodily fluids, then
hands washed with soap and water. Disinfection with alcohol-based gels
or alcoholsoaked cotton swabs will not suffice.
For patients on transmission-based precautions, all visitors were attired
w/ appropriate PPE.
Performed hand hygiene, if gloves were donned. Performed before
seeing next patient and/or leaving patient area.
Invasive Procedures
Before seeing a patient, gathered needed equipment first and then
performed hand hygiene.
Performed hand hygiene before contact with each patient, preferably
before entering the room or patient area
Donned gloves before performing any procedures
Donned gowns in situations that posed potential for the splattering of
URAGA PRIMARY HOSPITAL HAND HYGIEN MONITORING AND
SURVEILLANCE FORMS

blood or body fluid onto clothing

Donned masks, glasses/goggles, or face shields in situations where there
was potential of mucous membrane exposure of the face to blood or
body fluids.
Patient was on transmission-based precautions; appropriate PPE donned.
Patient was on transmission-based precautions; PPE was removed and
discarded in the room, or nearest waste receptacle, when procedure is
finished.
Adhered to safe disposal or sterilization of medical equipment guidelines
Ensured the gloves were removed and discarded within the room, or
nearest waste receptacle, when interaction with patient is finished.
Medication Administration
Once meds dispensed nurse proceeded directly to patient room/area.
Hand hygiene performed before contact with each patient.
Needed to perform additional tasks before entering patient room/area.
Hand hygiene performed just before contact with each patient.
Patient was on transmission-based precautions; appropriate PPE donned.
Appendix G: Page 1 of 2
Patient was on transmission-based precautions; PPE was removed and
discarded in the room, or nearest waste receptacle, before seeing next
patient or exiting patient area.
Hand hygiene performed before seeing next patient or exiting patient
area.
For patients on transmission-based precautions, visitor attired w/
appropriate PPE.
Passing Meal Trays
Performed hand hygiene before entering first room to pass food tray (not
on transmission-based precautions).
Delivered tray, then consistently performed hand hygiene when exiting
each room.
Was interrupted during tray passing after exiting the room to do another
task. Performed hand hygiene before passing the next tray.
Patient was on transmission-based precautions; appropriate PPE donned.
Patient was on transmission-based precautions; PPE was removed and
discarded in the room when exiting.
Patient was on transmission-based precautions: Trays passed last.
 URAGA PRIMARY HOSPITAL HAND HYGIEN MONITORING AND
SURVEILLANCE FORMS

Phlebotomy
Specimen obtained according to policy (Gloves donned, arm band
checked, venous access assessed, tourniquet applied, skin prepped w/
alcohol, blood drawn, sharps disposed in sharps container)
Specimen labelled & placed in plastic bag, placed on cart outside room.
Gloves removed & placed in waste basket in room.
Repeat hand hygiene
Patient was on transmission-based precautions; specimens obtained last.
Patient was on transmission-based precautions; appropriate PPE donned.
Hand hygiene=wash with soap and water or alcohol hand rub

Hand hygiene Sinks (ward and other areas) Soap

Alcohol based hand rub
Personal Towels
Paper Towels