DATE

NO. OF DAYS IN
1 2 3 4 5 6 7
HOSPITAL

TEMPERATURE
RESPIRATION

PULSE

TIME

42

41

180 40

39

160 38

37

140 36

35

120

60

50 100

40

30 80

20

10 60

URINE

STOOL
 FLUID INTAKE AND OUTPUT RECORD

NAME OF PATIENT: ________________________________

WARD / ROOM NO.: _______________________________

DATE TIME ORAL PARENTERAL TOTAL URINE DRAINAGE OTHERS TOTAL

 NURSES PROGRESS NOTES

PATIENT’S NAME: ______________________________________________ HEALTH RECORD NO.: _________________

SEX: ________ AGE: __________ WARD / ROOM NO.: __________________

DATE/TIME/SHIFT FOCUS D = Data A = Action R = Response

 MEDICATION SHEET

NAME: ______________________________________
WARD / ROOM NO.: ___________________________

MED.FREQ.DOSE

STAT. MEDS.

SIGNATURE:

NAME INITIAL FULL SIGNATURE

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