INTAKE AND OUTPUT RECORD

Name: ELLA S. MATABALAO Age/Sex: 48/F Date: 06-07-2021

Attending Physician: __________________ Room/Bed No. _______________

INTAKE OUTPUT

Time Oral IVF Others Total Time Oral IVF Others Total

Time Oral IVF Others Total Time Oral IVF Others Total

Time Oral IVF Others Total Time Oral IVF Others Total
TOTAL 24 Hour Intake TOTAL 24 Hour Output

Nurse on Duty Total Nurse on Duty Total

Nurse on Duty Total Nurse on Duty Total

Nurse on Duty Total Nurse on Duty Total

Checked by:

______________ _____________ _____________ ______________ _____________

______________ _____________ _____________ ______________ _____________