OBSERVATION RECORD

INFECTION CONTROL PRACTICES DURING POINT OF CARE BLOOD GLUCOSE TESTING

Center______________________
Date_______________________
Observer____________________

A New Single-Use Auto- Glucometer Cleaned and Disinfected

Hand Hygiene Before and
Gloves Worn Disabling Lancing Device After Use
After Patient Contact
Name of Personnel Observed (Mark the Used (Mark the appropriate
(Mark
appropriate column) (Mark the column - select N/A if patient's own
the appropriate column)
appropriate column) glucometer used)
Yes No Yes No Yes No Yes No N/A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Totals
Percent Adherence*

* For hand hygiene, glove use, and lancing device columns, Total number of "Yes" ÷ Number of rows with data x 100
For glucometer column: Total number of "Yes" ÷ ( Number of rows with data - Number of "N/A") x 100