Hand Hygiene Policy Version 2.0 - Ipswich Hospital

APPENDIX 3 - HAND HYGIENE OBSERVATION SHEET
HAND HYGIENE OBSERVATION SHEET
The observation sheet is intended to look at all groups of staff. If necessary move around the ward
so you can observe all staff groups. The audit of hand hygiene compliance should be undertaken at
the point of patient care and after any activity or contact that potentially results in hands becoming
contaminated, ie if in contact with anything within the patient curtain area.
Date ..................... Time …………….. Location of audit ………………………………
Observer’s Name & Designation …………………………………………..………………
Observe for a 20 minute period or for a
minimum of 20 hand hygiene opportunities
Please complete audit tool indicating:
‘O’ for a hand hygiene opportunity
‘H’ for observed hand hygiene (unchallenged)
‘C’ for observed hand hygiene (when challenged)
If a member of staff has to be challenged to perform hand hygiene at an appropriate
opportunity, please STOP them and discuss this with them and record as ‘C’
if they then perform hand hygiene.
If a staff member has to be challenged regarding hand hygiene record
their full name and designation next to the hand hygiene opportunity.
Nurses / HCA
Allied Health
Professionals
(eg Physiotherapists /
Occupational Therapists)
Doctors
Example:
O – H
O – H
O – C (record name +
designation)
O – C (record name +
designation)
O – H
O – H
O
(record
name+designation) Others
(health care workers eg Porters /
Ward Assistants – NOT
PATIENTS / VISITORS)
Percentage compliance for both unchallenged and challenged hand hygiene will be reported:
Unchallenged:
Challenged:
Compliance = observed hand hygiene (H) x 100 = ___ % Compliance = observed hand hygiene (H+C) x 100 =___ %
hand hygiene opportunities (O)
hand hygiene opportunities
PLEASE RETURN AUDIT FORMS TO: Nursing & Quality Administrator
Registered Document 472 Page 14 of 15
Hand Hygiene Policy v2.0 Implementation Date 25 February 2009