NAME: __________________________ AGE: _______ ROOM NO: _________ DATE: ________

INTAKE OUTPUT
IV FLUIDS ONGOING DRIPS/BT FEEDING CT

TOTAL INTAKE

MISC. /OTHER
DRAINS
IV DRIPS

OUTPUT
STOOL

TOTAL
URINE
ORAL MEDS

NGT/VOMIT
RIGHT
WATER

LEFT
OF
8
9
10
11
12
1
2
3
7AM TO 3PM: _____________________ TOTAL: TOTAL:
3PM-11PM: ______________________ TOTAL: TOTAL:
4
5
6
7
8
9
10
11

12
1
2
3
4
5
6
7
11PM-7AM: ______________________ TOTAL: TOTAL: