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24 HOUR FLUID INTAKE AND OUTPUT

Hospital No.: ________________


Case No.:______________ ROOM / BED NO.____________
Name Last First Middle Age Gender

Date of Birth Diagnosis Attending Physician

INTAKE OUTPUT

STOOL
DATE TIME ENTERAL PARENTERAL TOTAL URINE DRAINS OTHERS TOTAL
Characteristic frequency Consistency

0600
0700
0800
0900
1000
1100 750
1200
1300 200
8 HOUR INPUT
& OUTPUT 950ML

1400
1500
1600
1700
1800
1900 -
2000
2100 360
8 HOUR INPUT
& OUTPUT 360

2200
2300
2400
0100
0200
0300 640
0400
0500 250
8HOUR INPUT
& OUTPUT 890
24 HOURS
TOTAL

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