Resident Change of Condition Note for CNAs

Front-line observation form for CNAs to report new or worsening resident signs and symptoms to the licensed nurse with clear, time-stamped documentation.

Report Overview

• Date and time observed
  When you first noticed the change in condition.
• Resident identifier
  Enter the resident's facility-approved identifier or room number. Do not enter unnecessary PII.
• Reported to licensed nurse
  Name or role of the licensed nurse notified.
• Date and time reported
  When you notified the licensed nurse.

Observed Change

• Type of change observed
• Describe what you observed
  Use objective, observable facts. Avoid diagnosis or speculation.
• Was the onset time known?
• Approximate onset date and time
  Show this field when the onset is known or reasonably estimated.

Focused Observation Details

• Pain score
  Use a 0-10 scale if the resident can self-report.
• Pain location
  Where the resident indicated discomfort.
• What changed in mental status?
• Respiratory observation
• Skin or wound observation
• Nutrition or hydration concern

Immediate Actions Taken

• Actions taken before nurse review
• Were vital signs obtained?
• Vital signs summary
  Enter only if obtained and within your scope of practice. Include the minimum necessary details.

Escalation and Follow-Up

• Nurse response
• Follow-up instructions received
  Document any instructions from the licensed nurse.
• Additional notes
  Include any other relevant objective observations not captured above.