KULWANT NURSING HOME, MANSA

CHECK LIST FOR INDOOR (IPD) DEPARTMENT

PT. ID:----------------------- IPD No:------------------------------- DOA:----------------------- TIME:-------------

PATIENT NAME:----------------------------------------------------------- DOD:------------------------ TIME:-------------

PARTICULAR TICK IF AVAILABLE REMARKS

FRONT INDOOR SHEET

DOCTOR RX FOR ADMISSION

GENERAL CONSENT / REQUEST FORM

OTHER PRE OPERATIVE CONSENTS

SURGERY CONSENT FORM

INITIAL ASSESSMENT BY CONSULTANT

NURSING ADMISSION ASSESSMENT

DOCTOR ORDERS/PROGRESS RECORD

NURSING PROGRESS CHART

DOCTORS ORDER

NURSES RECORD

PRE-OP. MEDICATION

PRE/INTRA/POST OP. ASSESSMENT

O.T. NOTES

DISCHARGE SUMMARY

MEDICAL TEST REPORTS

OTHER DOCUMENTS

DATE / TIME SIGN & STAMP

MRD I/C
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph: 01652-502507, 94649-59146

GENERAL CONSENT FOR ADMISSION

I, Mr/Ms…………………………………………………………………………………………. Age/Sex: ………………………….…..S/D/W of

Sri/Smt ……………………………………………………………………….A resident of ……………………………………………………………

have been informed by Dr …………………………………………………………that I/my patient requires admission to the

hospital.

1. I have been explained about the treatment planned, expected outcome and possible complications.

2. I understand that my change in plan of treatment/medicines advised/increase in duration of stay will

affect the total cost of treatment.

3. I authorize my treating doctor to take appropriate decision regarding my treatment if so required in any
unforeseen situation.

4. I have been informed that any cash, jewellery or other valuable kept with me during hospitalization will e
completely at my risk and shall not hold the hospital responsible for any loss or theft.

5. I have been informed that in case any I/my patient will require any surgery/invasive procedure, I shall be
informed for the same.

6. I undertake the responsibility of clearing all the dues payable to the hospital during the patient’s stay in
the hospital. In case of any eventuality happening to the patient, I promise to pay the full payment of due
amount either by me or by the legal heirs of the patient immediately.

Signature of Patient ……………………………….. If patient is not competent to give consent,

Name ……………………………………………………… relative to give the same.

Date ………………………………………………………..

Time ………………………………………………………. Signature of Patient’s Relative ………………………….

Name ……………………………………………………………….

Signature of the Receptionist Relation with Patient ……………………………………….

Name …………………………………………………….. Date …………………………………………………………………

Date ….……………………………………………………

Time ……………………………………………………….
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 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Consent Form for HIV Testing and Pretest Counseling

This is a Confidential Document

Name: ………….……….… S/o, D/o, W/o, H/o…………………….……………. MR No………………..…………

Address……………………………………………………………………… Age/Sex ………………..………………...

Married: Yes/No ……..................... Occupation……………………….. Mob. No.…………………………………

Counselor's Commitment:

I hereby state that the patient / client has been counseled about the HIV test and has been explained about the
implication of the test result. All details pertaining to HIV, its transmission, prevention, testing procedures, its
limitations and interpretation of result have been explained and the patient / client has given his/her free and
informed consent to conduct an HIV test on him/her. I, the counselor, will do everything possible to assure that
the consent of the counseling session and the test result will be kept confidential.

Date…………………… Signature of Counselor

(Name in Capital Letters)

PATIENT'S / ATTENDANT'S INFORMED CONSENT TO TEST FOR HIV

This is to state that I have been counseled about the HIV test and have been explained about the implication
of

The test result. All the details pertaining to HIV, its transmission, prevention, test procedures, its limitation and

Interpretation of the result have been explained to me in a manner that I can understand,

I, hereby, give my consent for the test (s) to be conducted in order to ascertain my HIV sero-status.

ieh ik mYNnUM AYc.AweI.vI. tYst krn bwry smJw id~qw igAw Hy Aqy iesdy
tYst dy pRBwv bwry vI jwxU krvw

id~qwhY[ tYst sMbMDI swrI jwxkwrI, iesdy pRswrx, bcwA, tYst krn dw
qrIkw, iesdI sImw Aqy iesdy

cMgy mwVy nqIijAW bwry cMgI qrWH myrI AwpxI BwSw ivc smJw id~qw igAw
hY[

mYN swrI jwxkwrI qON bwAd ieh tYst krx dI mMjUrI idMdw/idMdI hW[
imqI: mrIj dy dsqKq

INFORMED CONSENT FOR SURGERY

Date- ……………………………

Patient Name- ………………………………………………...Age/ Sex- ………………DOA- ………………..Reg No.- …………………........

Consultant- …………………………………………………….Diagnosis- ………………………………………………………………………………....

I Authorize Dr……………………………………………………….and his team for the performance of the following

procedure/Surgery which is necessary to treat me/my patient’s condition:

(Procedure(s) to be performed):

…………………………………………………………………………………………………………………………………………………................

I have been explained about this consent form, which I fully understand and have understood the information
provided to me.
Risks: The authorization is given with the understanding that any procedure involves some risk and hazards like
infection, bleeding, nerve injury, blood clots, heart attack, in rare situation death and allergic reactions etc. They
can be serious and possibly fatal.
Alternative, Benefit & Complication: Further, I have been explained in my own language that the intended
benefits, possible complication, and available alternative to the said operation/procedure. I am also aware that
result of any operation/procedure can vary patient to patient; and I declare that no guarantees have been made
to me regarding success of this operation/procedure. I am aware that while majority of patient have an
uneventful operation and recovery, few cases may be associated with complication. I am aware of the common
risk as explained and complications associated with the operation/procedure and also understand that it is not
possible to list all possible complications of any operation/procedure.

Possible Risks & Complications commonly faced:

…………………..…………………………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………….
...............................................................................................................................................................................................................................

Photography: I consent to the photographing or telecast of procedures to be performed, including appropriate

portion of my body for medical, scientific or educational purposes, provided my identity is not revealed.
I certify that I have read and fully understood the above consent after adequate explanations were given to me.
Signature or Patient: ……………………………………………….…..Date& Time:…………………………..……………………………

Relative’s Name: …………………………………………………………………….. Signature: …………………………………..…………..

Relation: …………………………………………………….. Date/Time: ………………………………………………………………………...

(Reason: Minor Unconscious Drowsy Mentally Physically Challenged)

 DECLARATION BY DOCTOR

I,……………………………………………………………………. (Name of Doctor) hereby, state that the patient has been
explained about the implication of the operation in the vernacular.
Signature of Doctor: …………………………………………………..Date:……………………………... Time: …………………………
 e[btzs Bof;zr j'w n?Av fJzv';e'ghe
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c'BL 01652^502507, 94649^59146
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sohy
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HHHHHHHHHHHHHHHH
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uzrh soQK dZ; fdZsk j?. fJ; ftZu e[M th b[e' S[g' e/ Bjh oZfynk frnk
j?.

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 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

DOCTORS INTITIAL ASSESSMENT

______________________________________________________________________
PATIENT’S NAME …………………………… AGE/SEX ……………IP No……………..…..UHID No…………….……
_________________________________________________________________________________

1. COMPLAINTS AND DURATION

2. HISTORY OF PRESENT ILLNESS

3. HISTORY OF PAST ILLNESS

 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

PATIENT’S NAME …………………………… AGE/SEX ……………IP No……………..…..UHID No…………….……

_________________________________________________________________________________

4. TREATMENT HISTORY ______________________________________________________

4.1 Diabeties – No/Yes, Details ____________________________________________
4.2 Hypertension – No/Yes, Details ________________________________________
4.3 CAD – No/Yes, Details ________________________________________________
4.4 Asthma – No/Yes, Details _____________________________________________
4.5 Tuberculosis – No/Yes, Details _________________________________________
4.6 Antibiotics –No/Yes, Details ___________________________________________
4.7 Hormons – No/Yes, Details ____________________________________________
4.8 Chemo/Radiation – No/Yes, Details _____________________________________
4.9 Blood Transfusion – No/Yes, Details _____________________________________
4.10 Surgeries –No/Yes, Details ___________________________________________
4.11 Other – No/Yes, Details ______________________________________________

5. PERSONAL HISTORY
5.1 Single/Married 5.2 Occupation
5.3 Appetite – Normal/Lost 5.4 Veg/Non-Veg/Eggtarian
5.5 Bowels-Regular/Irregular/Constipation
5.6 Micturition-Normal/Abnormal, Details
5.7 Know Allergies-No/Yes, Details
5.8 Habitas/Addictions
a. Alcohol – Regular/Occuaasion/Teetotaler
b. Tobacco – Sniff/Chewable/Smoking-Pack Years
c. Drug use – No/Yes, Details
d. Betel nut – No/Yes, Details e. Betal Leaf (plan)-No/Yes

6. FAMILY HISTORY
6.1 Diabeters-No/Yes, Details
6.2 Hypertension-No/Yes, Details
6.3 Heart disease-No/Yes, Details
6.4 Stroke-No/Yes, Details
6.5 Cancers-No/Yes, Details
6.6 Tuberculosis-No/Yes, Details
6.7 Asthama-No/Yes, Details
6.8 Any other hereditary Disease
6.9 Psychiatrist illness
6.10 Sibling History
6.11 Any other
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
PATIENT’S NAME …………………………… AGE/SEX ……………IP No……………..…..UHID No…………….……
_________________________________________________________________________________

7. MENSTURAL HISTORY ______________________________________________________

7.1 Age of Menarche:
Duration of Cycle
7.2 Menstrual Cycle = ------------------------- (PAST) (PRESENT)
No. of days of Bleeding
7.3 LMP _____________________________
7.4 Any Gyneacological problems; Not Yes, details _________________________________
8. OBSTETRIC HISTORY
8.1 Age at marriage ___________________ 8.6 No. of living children ________________
8.2 Age at first child birth ______________ 8.7 Family planning methods used
8.3 Gravida __________________________ Oralpills/IUD/IVD permanent sterilization
8.4 Para ____________________________ 8.8 No of Abortions ____________________
8.5 Still birth _________________________
8.6 Others ___________________________
9.1 BIRTH HISTORY
a) FIND/Caesarean Delivery/Delivery By Vacuum Suction/Forceps Delivery
b) History of Birth Asphyxia – No/Yes
9.2 DEVELOPMENTAL HISTORY (As per IAP Guidelines)
Normal/Abnormal, details _____________________________________________________
__________________________________________________________________________
9.3 IMMUNIZATION STATUS (As per IAP Guidelines)
Up to mark/Not upto mark
10. PHYSICAL EXAMINATION
A. GENERAL
1. Height _____________________ 2. Weight _________________________
3. BMI _______________________ 4. Body Surface area_________________m2
5. Pallor –No/Yes 6. Icterus – No/Yes
7. Cyanosis – No/Yes 8. Clubbing of fingers/toes – No/yes
9. Lymphadenopathy-No/Yes 10. Oedena if feet – No/Yes
11. Mainutrition – No/Yes
12. Dehydration – No/Yes – Mild/Moderate/Severe
13. Temperature _____________________C/F
14. Pulse Rate ________________/ min
15. Respiration (Count for a full min) Rate) ____________________________/min.
16. BP Lt. _____________________ Arm mm/Hg: Rt. Arm ______________mm/Hg
17. SPO2 at Room air _______________________% / at ______________ litres of 02
18. GRBS______________________mg%
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

PATIENT’S NAME …………………………… AGE/SEX ……………IP No……………..…..UHID No…………….……

_________________________________________________________________________________
SYSTEMIC EXAMINATION:
B. CARDIO VASCULAR SYSTEM
1. Thrills No/Yes 2. Cardiac sounds
3. Cardiac murmurs No/Yes
C. RESPIRATORY SYSTEM
1. Dyspnoea – No/Yes 2. Wheeze – No/Yes
3. Position of Trachea-Central/Shifter to Right 1 Left
4. Breath Sounds-Vesicular/Tubelar/Amphoric
5. Adventitious Sounds-Rhonchi/Rales (Crepts) I Pleural rub
D. ABDOMEN
1. Shape of abdomen-Scaphoid/Obese/Distended
2. Tenderness-Not Yes, details _______________________________________
3. Palpable mass-No Yes, details _____________________________________
4. Hernial Orifices-Normal/Hernia, details ______________________________
5. Free Fluid-No/Yes 6. Bruits-No/Yes
7. Liver-Not palpable/Palpable, details _________________________________
8. Spleen-Not palpable/Palpable, details _______________________________
9. Bowel sounds-No Yes
10. Genitals 11. Speculum Examination
12. PV Examination 13. P/R Examination
E. CENTRAL NERVOUS SYSTEM
1. Level of Consciousness a. Conscious/Alert b. Drowsy 1 Arousable c. Stuporous d. Coma
2. Speech-Normal/No Response/Slurred/Incoherent/Aphasic
3. Sign of Meningeal Irritation a. Neck Stiffness- No Yes b. Kerning’s Sign- No Yes
4. Cranial Nerves 5. Motor System 6. Sensory System 7. Glasgow Scale
F. LOCAL EXAMINATION
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

PLAN OF CARE
______________________________________________________________________
PATIENT’S NAME …………………………… AGE/SEX ……….……IP No…….…………..UHID ..…………….……
_________________________________________________________________________________

PROVISIONAL DIAGNOSIS/DIAGNOSIS:

PLAN OF CARE:

EXPECTED OUTCOME (PROGNOSIS):

PREVENTIVE ASPECTS OF CARE:

NAME SIGNATURE
DATE TIME

KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA

Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
DOCTOR’S ORDERS/PROGRESS RECORD

PATIENT’S NAME ………………………………………….IP No………………….…..UHID …………...…………….……

SEX ……………………AGE………………………Ward………….......Wt………………….Blood Group…………………
Diagnosis………………………………………………………………………….Consultant…………………………………….
Date & PROGRESS NOTES Name & Signature
Time
KULWANT NURSING Name of Patient …………………..……………………….. Age/Sex………..…..
HOME & ENDOSCOPIC UHID.No/IPD No ………………….………….Room/Ward No………….…….
SURGICAL CENTRE
Date of Operation ……………………………D.O.A…………………….…………
MANSA

PRE ANAESTHESIA CHECK UP (PAC) & PRE OPERATIVE RECORD

Diagnosis: Alert/Allergies

Operation ASA 1 2 3 4 5 6 E NYHA : I II III IV

Anaesthesia Plan: Consent: Informed/High Risk

Blood Gp. Wt.(kg) Temp HR/ B.P. R.R.

Rhythm
Previous H/O illness/Surgery/Anesthesia: Medications

General Examination Airway Spine

General Condition Exercise Tolerance Mouth Opening
Pallor Oedema Neck Movement
Cyanosis Oral Hygiene Mallampati Grade
Icterus Dentures Mentothyroid Distance

Systemic Examination
CVS
Pulmonary
CNS
Venous Access
Investigations B.Sugar: S.Proteins X-Ray:
Albumin:
HB: B.Urea: Globulin: ECG:
TLC: S.Creatinine: HBsAG: ECHO:
DLC: SGOT/SGPT: HCV:
Platelets: Alk.Po4: HIV:
Urine C/E:
BT/CT: S.Amylase: Na+:
PTINR: K+:
Pre anesthetic Instructions Anesthetic Plan
Preoperative
Medications:

Route: Time: Date:

Name and Signature of Anesthetist
 KULWANT NURSING
HOME & ENDOSCOPIC Name of Patient …………………..……………………….. Date……………..…..
SURGICAL CENTRE
Age & Sex ……………………………UHID/IPD No …………………….………….
MANSA
PRE INDUCTION ASSESSMENT
Pulse: RR: BP: ECG: RS: CVS: OTHERS:

Any Significant change in condition: Yes…………….. No………….

Fit to get anaesthetized as per plan, Change of plan required.

Prophylactic Antibiotic: Drug Dose Time

WHO safety check List Completed Yes No Sign & Name Anaesthetist

Date & Time

ANAESTHESIA NOTES
Diagnosis : ……………………………………………………………………………………………………………………………………….

Operation : ………………………………………………………………………………………………………………………………………
Pre Medication ……………………………………………………………………………………………………………………………….

Type of Anaesthesia ………………………………..……………… SPINAL/GA/LOCAL/EPIDURAL BLOCK

Surgeon …………………........... Anaesthetist ………………………………………..Assistants ……………………………..

Time & Date:-

A.S (Anaesthesia Started) …………………………………. O.S (Operation Started) ……………………………………

O.F (Operation Finished) …………………………………… P.S (Patient Shifted from …….…………………………….
Notes:-
Vitals (To be checked after ten minutes interval)

Time
Pulse Rate
B.P
SPo2
I/V Fluids
I/V Drugs

Signature of Anaesthetist
Date:-
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

OPERATION NOTES

Patient Name …………………………………..………..……Age………………..Sex…………….

UHID …………………………………………………………IP No………………………………..

Consultant…………………………………………………………………………………………….

Bed No/Room No/Deptt No ………………………………………………………………………….

Date of Admission …………………………………………………………………………………...

Diagnosis ……………………………………………………………………………………………..

Operation Performed …………………………………………………………………………………

Date & Time …………………………………………………………………………………………

Surgeon ………………………………………………………………………………………………

Anaesthetist …………………………………………………………………………………………..

Details…………………………………………………………………………………………….......

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KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA

Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

NURSING ADMISSION ASSESSMENT

Name of the Patient ……………..……………Age/Sex……………..UHID……………….IP Reg.No……………..…..………

Room No……………………..Deptt…………………………..Bed No…………………Date…………………Time………………..

General Information Time of Arrival …………………………

Mode of Admission Walking/Wheelchair/Stretcher Patient accompanied on admission : Yes/No
If Yes, Name ……………………………………………..Relation…………………………….Contact No………………………..
Primary Language spoken ……………………………….. Interpreter needed : Yes/No
Cultural Religious barriers Yes No If yes, describes: ……………………………………………………………
_________________________________________________________________________________
Vital Signs
Temp …………….Pulse………….SpO2…………..BP……………Resp………….Ht…………….Wt…………..GCS……………
_________________________________________________________________________________
Handing over of Patient’s Valuables: Relative Name …………………………………..
Valuable handed over to attendant: Yes No Signature……………………………………………
1……………………………………2……………………………………..3…………………………….4………………………………………..
-------------------------------------------------------------------------------------------------------------------------------------
Allergies/Adverse Reaction Known Not Known N/A
If known/suspected allergies to ………………………………………………………………………………………………………….
Reaction to previous transfusion: Yes No Food allergy: Known Unknown N/A
Diet ……………………………………………………………………………………………………………………………………………………
Current in Medications (as used by patient at the time of admission)
Name of Drug Dose Frequency Date/Time of last dose
1……………………………………….. ……………………………… …………………………… …………………………………………
2……………………………………….. ……………………………… …………………………… …………………………………………
3……………………………………….. ……………………………… …………………………… …………………………………………
4……………………………………….. ……………………………… …………………………… …………………………………………
5……………………………………….. ……………………………… …………………………… …………………………………………
6……………………………………….. ……………………………… …………………………… …………………………………………
7……………………………………….. ……………………………… …………………………… …………………………………………
Medicines brought to the hospital: Yes No

Pain Score: (0-10) …………………………………………….

0 2 4 6 8 10
NO HURT HURTS HURTS HURTS HURTS HURTS
LITTLE BIT LITTLE MORE EVEN MORE WHOLE LOT WORST
KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph: 01652-502507, 94649-59146

NURSES’S PROGRESS CHART

Patient’s Name …………………………………………UHID………………IP Reg No………………………Age/Sex……….…..

Room No………………………Bed No……………………Deptt……………………………..……………….Date…………………..

Date/Time Progress Chart Sign

KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph: 01652-502507, 94649-59146

NURSES’S PROGRESS CHART

Patient’s Name …………………………………………UHID………………IP Reg No………………………Age/Sex……….…..

Room No………………………Bed No……………………Deptt……………………………..……………….Date…………………..

Date/Time Progress Chart Sign

 PT. NAME: ______________________________

DOA: _________________ Age/Sex: ________

UHID: _______________ IP No: ____________

Consultant:_____________________________

DOCTOR ORDER SHEET

DATE & DOCTOR NOTES NAME &
TIME SIGN
 PT. NAME: ______________________________

DOA: _________________ Age/Sex: ________

UHID: _______________ IP No: ____________

Consultant:_____________________________

DOCTOR ORDER SHEET

DATE & DOCTOR NOTES NAME
TIME & SIGN
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146
MEDICATION CHART
IPD/UHID No………………………………………….BED No……………………………………DATE………………………………..
Allergy to ……………………………………………………………….. Name…………………………………………………………….
Date NAME OF DRUG ROUTE FREQ SPL.INSTR GIVEN AT (TIME & SIGN OF NURSE)
WITH STRENGHT UCTION TIME SIGN TIME SIGN TIME SIGN
Date NAME OF DRUG ROUTE FREQ SPL.INSTR GIVEN AT (TIME & SIGN OF NURSE)
WITH STRENGHT UCTION TIME SIGN TIME SIGN TIME SIGN
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

VITAL CHART
Patient’s Name …………………………………………Age/Sex………………Deptt………………………Bed No………….…..

UHID………………………………………………….IP Reg No………………………………………….Date……………………………..

Date and Pulse Blood Temp Resp SPO2 Pupil G.C.S Sign
Time Pressure
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

VITAL CHART
Patient’s Name …………………………………………Age/Sex………………Deptt………………………Bed No………….…..

UHID………………………………………………….IP Reg No………………………………………….Date……………………………..

Date and Pulse Blood Temp Resp SPO2 Pupil G.C.S Sign
Time Pressure
 KULWANT NURSING HOME & ENDOSCOPIC SURGICAL CENTRE MANSA
Water Works Road, Near Water Works, Mansa
Ph : 01652-502507, 94649-59146

INTAKE & OUTPUT REPORT

Patient’s Name ……………………………….Age/Sex………………Deptt……………..Bed No………..….
UHID …………………………………………IP Reg. No……………………………………Date……………………..
PREVIOUS BALANCE REPLACEMENT OF LOSSES
INTAKE OUTPUT
DATE & ORAL INTRAVENOU RYLE’S DATE& STOOL URINE R/T VOMIT REMAR
TIME S TUBE TIME ASPIRN KS
 PREVIOUS BALANCE REPLACEMENT OF LOSSES
INTAKE OUTPUT
DATE ORAL INTRAVENOUS RYLE’S DATE STOOL URINE R/T VOMIT REMARKS
& TUBE & ASPIRN
TIME TIME