ION MEDICAL CENTER

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

No.: (+632) – 881 – 1571

INTAKE AND OUTPUT SHEET

NAME: Alleah ‎‎ ‎‎‎‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎‎‎‎‎‎‎‎‎ ‎‎‎‎‎‎‎‎‎‎AGE: 8 y/o‎‎‎‎‎‎‎‎ ‎‎ ‎‎ ‎‎‎‎‎‎‎‎‎‎HOSPITAL NO.: ‎112222‎‎‎ ‎‎ ‎‎ ‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎
SERVICE: Pediatric ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎‎ ‎ SEX: Female ‎‎ ‎‎‎ ‎‎‎‎‎‎‎‎‎WARD/RM: Room 1‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎
ATTENDING PHYSICIAN: ‎Dr. Ga‎ ‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎‎ ‎‎‎‎‎‎‎‎‎
COAHS-CON2018-RLE-IOS

INTAKE OUTPUT

DATE TIME ORAL TUBE I.V. 8-HR DATE TIME URINE STOOL OTHER 8-HR
FEEDI TOTAL S TOTAL
NG
9-21 NIGHT 1x 1x soft and N/A 1x urine
9-21 NIGHT 170ml N/A 486 656ml -22 formed stool + 1x BM
-22 ml
9-21 A.M. 2x 1x soft and N/A 2x urine
9-21 A.M. 120ml N/A 570ml 690ml -22 formed stool + 1x BM
-22
9-21 P.M. 1x 2x soft and N/A 1x urine
9-21 P.M. 280ml N/A 430ml 710ml -22 formed stool + 2x BM
-22
9-21 24-HR 4x 4x soft and N/A 4x urine
9-21 24-HR 550ml N/A 1483 2,056ml -22 TOTAL formed stool + 4x BM
-22 TOTAL ml
OUTPUT
INTAKE
DATE TIME URINE STOOL OTHER 8-HR
DATE TIME ORAL TUBE I.V. 8-HR S TOTAL
FEEDI TOTAL
NG 9-22 NIGHT 2x 0 N/A 2x urine
-22
9-2 -22 NIGHT 100ml N/A N/A 100ml
9-22 A.M. 1x 1x soft and N/A 1x urine
9-22 A.M. 110ml N/A 114 224ml -22 formed stool + 1x BM
-22 ml
9-22 P.M. 1x 1x soft and N/A 1x urine
9-22 P.M. 300ml N/A N/A 300ml -22 formed stool + 1x BM
-22
9-22 24-HR 3x 2x soft and N/A 4x urine
9-21 24-HR 510ml N/A 114ml 624ml -22 TOTAL formed stool + 2x BM
-22 TOTAL
OUTPUT

INTAKE

DATE TIME URINE STOOL OTHERS 8-HR

TOTAL
DATE TIME ORAL TUBE I.V. 8-HR
FEEDING TOTAL
A.M.

A.M.
P.M.

P.M.
NIGHT

NIGHT
24-HR
TOTAL
24-HR
TOTAL