Handwashing is one of the most effective ways to prevent infection transmission among patients and personnel and is the single most important means of preventing the spread of infection.

📚 Resources Needed

  • Handwashing facilities in the exam room and/or utility room

  • An adequate supply of running potable water

  • Soap

  • Single-use towels or a hot-air drying machine

  • An antiseptic hand cleanser, alcohol-based hand rub, or antiseptic towelettes for temporary use when running water is not readily available

✅ Before You Start

  • Locate the handwashing facility in the exam room and/or utility room.

  • Confirm running potable water, soap, and single-use towels or a hot-air drying machine are available.

  • Use an approved temporary antiseptic cleanser, alcohol-based hand rub, or antiseptic towelette only when running water is not readily available.

🚀 Tips & Tricks

  • When in doubt about whether handwashing is necessary, wash your hands.

  • Treat both entering and leaving the room as required handwashing points.

  • Keep approved temporary hand-cleansing products accessible for occasions when running water is not readily available.

📘 Instructions

Step 1: Confirm The Handwashing Facility Is Ready

  • Use the handwashing facility in the exam room and/or utility room.

  • Confirm the facility has an adequate supply of running potable water, soap, and either single-use towels or a hot-air drying machine.

Step 2: Wash Upon Entering And Leaving The Room

  • Perform thorough handwashing upon entering the room.

  • Perform thorough handwashing again when leaving the room.

Step 3: Wash At Every Required Point Of Care

  • Wash hands before and after contact with a patient.

  • Wash hands before performing invasive procedures.

  • Wash hands before caring for newborn infants.

  • Wash hands before and after touching wounds.

  • Wash hands after touching inanimate sources that are likely to be contaminated, including specimen containers or bed linens.

Step 4: Perform Routine Handwashing Correctly

  • Wet hands using running potable water and apply soap.

  • Vigorously rub the soap-lathered hands together for at least ten seconds.

  • Thoroughly rinse the hands under a stream of water.

  • Dry the hands using a single-use towel or a hot-air drying machine.

Step 5: Use An Approved Temporary Alternative When Water Is Unavailable

  • When running water is not readily available, use an antiseptic hand cleanser, alcohol-based hand rub, or antiseptic towelettes.

  • These alternatives are acceptable only until running water becomes available.

Step 6: Wash Whenever There Is Doubt

  • Perform handwashing whenever personnel are in doubt about whether it is necessary.

🛠 Troubleshooting

Running Water Is Not Readily Available

Use an antiseptic hand cleanser, alcohol-based hand rub, or antiseptic towelettes until running water is available.

Soap Or A Drying Method Is Missing

Do not rely on an incomplete routine-handwashing station. Restore soap and either single-use towels or a hot-air drying machine.

You Are Unsure Whether Handwashing Is Necessary

Wash your hands. The protocol requires handwashing whenever personnel are in doubt.

✅ Completion Check

  • Handwashing facilities are available in the exam room and/or utility room.

  • The facility has adequate running potable water, soap, and single-use towels or a hot-air drying machine.

  • Approved temporary antiseptic hand-cleansing products are used only until running water is available.

  • Thorough handwashing is performed upon entering and leaving the room.

  • Hands are washed before and after patient contact, before invasive procedures, before caring for newborn infants, before and after touching wounds, and after touching likely contaminated items such as specimen containers or bed linens.

  • Routine handwashing includes vigorously rubbing soap-lathered hands together for at least ten seconds and thoroughly rinsing under a stream of water.

  • Personnel wash their hands whenever they are in doubt about the need to do so.

References

CalOptima Health Facility Site And Medical Record Review Audit Packet: Hand Washing, page 61

Source Protocol Revision: Apr 29, 2026

Internal readiness SOP only; the full CalOptima and applicable infection-control requirements control.