Snack and Nourishment Pass Log

Evening and HS (hour of sleep) snack pass documentation for nursing home residents, tracking supplement delivery, refusals, substitutions, and clinical notes to support nutritional care planning and MDS documentation.

Pass Round Details

• Unit / Wing
  Select the nursing unit or wing where this snack pass is being conducted.
• Pass Date
  Date the nourishment pass is being conducted.
• Pass Time
  Select the scheduled pass time for this round.
• Specify Other Pass Time
• Staff Member Conducting Pass
  Name of the dietary aide, CNA, or nursing staff member performing this nourishment pass.
• Staff Title / Role

Resident Nourishment Entries

• Resident Nourishment Log
  Enter one row per resident. All residents on the nourishment pass list must be documented, including those who refused.

Supplement Reference Key

• Supplements / Snacks Available This Pass
  Select all items that were stocked and available for distribution during this round.
• Additional Supplement or Substitution Notes

Refusals and Clinical Concerns

• Were any refusals documented during this pass?
• Total Number of Refusals
  Enter the total count of residents who refused the offered supplement or snack.
• Charge Nurse Notified of Refusals?
  Per facility policy, refusals of nutritional supplements must be reported to the charge nurse for care plan follow-up.
• Clinical Concerns Observed During Pass
  Select any clinical observations made during the nourishment pass. Report all checked items to the charge nurse immediately.
• Clinical Concern Details
  Document specific observations and actions taken. This narrative supports nursing follow-up and care plan updates.

Pass Summary and Attestation

• Total Residents on Nourishment Pass List
  Enter the total number of residents assigned to this pass round.
• Total Supplements / Snacks Successfully Delivered
  Enter the count of residents who received and accepted their supplement or snack.
• Total Not Delivered (Refusals + Unavailable)
  Enter the count of residents who did not receive their supplement (refusal, sleeping, absent, held per order, etc.).
• Time Pass Was Completed
  Record the time the nourishment pass round was fully completed.
• General Pass Notes
• Staff Attestation
  By checking this box, I attest that the information documented in this nourishment pass log is accurate and complete to the best of my knowledge, and that all refusals and clinical concerns have been reported to the appropriate clinical staff per facility policy.
• Staff Signature
  Electronic signature of the staff member who conducted and documented this nourishment pass.