RUMAH SAKIT No RM

LABEL PASIEN
:
UNIVERSITAS SEBELAS MARET Nama Pasien : ...............................................
Tgl Lahir : ...............................................
Jl. Jendral Ahmad Yani No 200 Makamhaji Kartosuro Alamat : ...............................................
Sukoharjo (Harap diisi atau tempelkan stiker bila ada)

BALANCE CAIRAN

Tanggal: INFUS: BB: kg

Jam INTAKE OUTPUT Balance Cairan

Infus/obat Makan/minum NGT Urine Muntah Drain BAB
07.00 Intake = cc
08.00 Output = cc
09.00 IWL = cc
_______________-
10.00
Total =
11.00 cc
12.00
13.00
Total

14.00 Intake = cc
15.00 Output = cc
16.00 IWL = cc
_______________-
17.00
Total =
18.00 cc
19.00
20.00
Total

21.00 Intake = cc
22.00 Output = cc
23.00 IWL = cc
_______________-
00.00
Total =
01.00 cc
02.00
03.00
04.00
05.00
06.00
Total

24 Jam Infus/obat Makan/minum NGT Urine Muntah Drain BAB IWL 24 Balance
= = = = = = = jam 24 jam
Intake= Output=