SWC NA Student Worksheet

Student Name:_____________________________ Date:_________________

Resident’s Rm #_________ Resident’s Dx____________________________________________________
RN/CN_____________________ LVN_____________________ CNA_____________________
V/S T - P- R- B/P- Recheck (if applicable)______________ Pain  Yes  No
ADLs  Partial or Complete Bed Bath  Shower  Oral or Denture Care  Hair Care  Nail Care
ROM Active  Passive Mobility  Immobile  Chair / Wheelchair  Ambulatory
Diet (type): _______________ or  TF Meal Intake (B%)_____ (L%)_____ Supplement (%)_____ _____ml
Fluid Intake (B) _____ml + (L)________ ml (Between meals) ________ml = Total Intake________ml

Fluid Output  Foley Catheter ___________ ml  Continent or  Incontinent # of episodes________

BM  Continent  Incontinent # of episodes_______ size______
Special Needs/ Equipment:
 RNA Program  Isolation  Hip Precautions  Oxygen ____LPM  PT/OT/ST/RT
 Restraint (type):______________  Pressure Ulcer (stage):____  Other_______________________
Social Activities: __________________________________________________________________________
Documents to chart & complete:
 Start of Shift Oral Report by LN/CNA  Vital Signs Record
 I/O  BM Record
 Turning Schedule  Bowel & Bladder
 Meal Book  End of Shift Oral Report to LN/CNA
Narrative Note (Please write a narrative note on the lines below in correct format as learned in Module 15)

Objective Observations Subjective Observations Reports Skills/Tasks Done Other Skills/Comments

JOF 2022