Standard Precautions- Observation of Personal Protective ...

[Pages:2]Standard Precautions: Observation of

5

Personal Protective Equipment Provision

Instructions: Observe patient care areas or areas outside of patient rooms. For each category, record the observation. In the column on the right, sum (across) the total number of "Yes" and the total number of observations ("Yes" + "No"). Sum all categories (down) for overall performance.

Standard Precautions: Observation Categories

Room 1

Are gloves readily available

1 outside each patient room or

any point of care?

q Yes q No

Are cover gowns readily

2 available near each patient

room or point of care?

q Yes q No

Is eye protection (face shields or

3

goggles) readily available near each patient room or point of

q Yes q No

care?

Are face masks readily available

4

q Yes

near each patient room or point q No

of care?

5

Are alcohol dispensers readily accessible and functioning?

q Yes q No

Room 2

Room 3

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

Room 4

Room 5

Summary of Observations Yes Total Observed

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

q Yes q No

Total YES and TOTAL OBSERVED

Standard Precautions: Observation of

5

Personal Protective Equipment Provision

Date:______________ Observer Role: o Nurse o Tech o Other__________ Initials:______ Location/Unit:____________

Notes and comments:

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