Templates › Forms › SEO page

Run: Snack and Nourishment Pass Log

Track evening and HS snack passes for nursing home residents, including supplement delivery, refusals, substitutions, and clinical notes in one log. Use it t...

Fill this out, get a PDF emailed to you. No account required. Want to run it with your team and track results? Sign up free →

Pass Round Details

Unit / Wing (required)

Select the nursing unit or wing where this snack pass is being conducted.

Pass Date (required)

Date the nourishment pass is being conducted.

Pass Time (required)

Select the scheduled pass time for this round.

Specify Other Pass Time

Staff Member Conducting Pass (required)

Name of the dietary aide, CNA, or nursing staff member performing this nourishment pass.

Staff Title / Role (required)

Resident Nourishment Entries

Resident Nourishment Log (required)

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 (required)

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? (required)

Total Number of Refusals (required)

Enter the total count of residents who refused the offered supplement or snack.

Charge Nurse Notified of Refusals? (required)

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 (required)

Enter the total number of residents assigned to this pass round.

Total Supplements / Snacks Successfully Delivered (required)

Enter the count of residents who received and accepted their supplement or snack.

Total Not Delivered (Refusals + Unavailable) (required)

Enter the count of residents who did not receive their supplement (refusal, sleeping, absent, held per order, etc.).

Time Pass Was Completed (required)

Record the time the nourishment pass round was fully completed.

General Pass Notes

Staff Attestation (required)

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.

Yes No N/A

Staff Signature (required)

Electronic signature of the staff member who conducted and documented this nourishment pass.

Get your results

Enter your email — we'll send you a PDF of your filled-out template, plus the occasional MangoScoop newsletter (templates, workflow tips, product updates). Unsubscribe anytime — link is in every email.

Email (required)

Your name (optional)

Generated with MangoApps Templates — browse 250+ free