Hydration Pass Documentation Log

Shift-level documentation of between-meal fluid offerings to at-risk residents in a nursing home setting. Captures volume offered, volume consumed, refusals, and clinical follow-up to support hydration monitoring and care plan compliance.

Pass Details

• Unit / Wing
  Select the unit where this hydration pass was conducted.
• Date of Pass
• Shift
• Time Pass Conducted
  Record the actual start time of this hydration round.
• Pass Timing
• Staff Member Conducting Pass
• Staff Title / Role

Fluid Offerings

• Type(s) of Fluid Offered
  Select all fluid types offered. Thickened liquids must match the resident's current diet order.
• Standard Volume Offered Per Resident (mL)
  Enter the standard serving size offered to each resident in milliliters (e.g., 240 mL = 8 oz).
• Total Residents on At-Risk Hydration List for This Unit

Resident-Level Intake Record

• Resident Fluid Intake Log
  Record each resident's room/bed, volume consumed, and outcome. Estimated consumption is acceptable if resident is unable to self-report; note 'estimated' in the remarks column.
• Outcome Code Reference
  Outcome options: 'Consumed ≥75%' | 'Consumed 50–74%' | 'Consumed <50% – Monitor' | 'Refused – See Reason' | 'NPO / Restriction' | 'Asleep / Not Disturbed' | 'Off Unit'. Refusal reasons: 'Declined – No Reason Given' | 'Nausea / Vomiting' | 'Dysphagia Concern' | 'Disliked Offering' | 'Fatigue' | 'Behavioral / Agitation' | 'Other – See Remarks'.

Pass Summary

• Number of Residents Offered Fluids This Pass
• Residents Who Consumed ≥75% of Offering
• Residents Who Consumed <50% of Offering
  These residents require charge nurse notification per facility protocol.
• Number of Residents Who Refused Fluids
• Residents Skipped Due to NPO Order or Fluid Restriction
• Were any clinical concerns identified during this pass?
• Describe Clinical Concerns Observed
  Include resident identifier, observation, and any action taken. Do not include full name if facility policy uses room/ID documentation.
• Was the Charge Nurse Notified of Any Concerns?
• Time Charge Nurse Was Notified

Attestation

• I confirm that all residents on the at-risk hydration list were approached during this pass, or a reason for exception is documented above.
• I attest that the fluid volumes and outcomes recorded are accurate to the best of my observation and knowledge.
• Time of Submission
  Record the time you are completing and submitting this log.
• Additional Notes for Charge Nurse or Dietitian (Optional)