COAHS MEDICAL CENTER

J. P. Rizal Extension, West Rembo, Makati City 1215

Telephone No. : (+632) – 881 – 1571

INTRAVENOUS FLUID SHEET

NAME: ___________________________________ AGE: ______________ HOSPITAL NO.: ______________

SERVICE: ________________________________ SEX: ______________ WARD/RM: __________________

ATTENDING PHYSICIAN: _________________________________________

IV AMOUNT DROPS REMARKS AND

IV TIME TIME AMOUNT AMOUNT
DATE FLUID IIV FLUID PER PER NURSES’
SITE STARTED FINISHED INFUSED LEFT
NO. SHIFT MINUTES SIGNATURE’S

COAHS-CON2018-RLE-GMS