INTAKE-OUTPUT CHART Registration number Name Date TIME INTAKE (ml) OUTPUT (ml) Urine N/G Drains Stool Method Site MORNING Aspirate etc. B.O. SHIFT Amount Type of Fluid Additions 07.00 a.m. Put up Gone in Remainder 2.00 p.m. Total at end of shift TIME INTAKE (ml) OUTPUT (ml) Method Site Urine N/G Drains Stool AFTERNOON Aspirate Stoma etc. B.O. SYIFT Amount Type of Fluid Additions 02.00 p.m. Put up Gone in 9.00 p.m. Remainder Total at end of shift TIME INTAKE OUTPUT Urine N/G Drains Stool Method Site NIGHT Aspirate Stoma etc. B.O. SHIFT Amount Type of Fluid Additions 09.00 p.m. Put up Gone in Remainder 7.00 a.m. Total at end of shift NOTES SHIFT TOTAL (ml) 24 HOUR BALANCE (ml) Morning Intake From To Output Date Date Time Time Afternoon Intake Total Intake Shift Output Total Output Night Intake Output Difference
INTAKE-OUTPUT CHART Name Registration number Date TIME INTAKE (ml) OUTPUT (ml) MORNING SHIFT Method Site Urine N/G Aspirate Drains etc. Stool B.O. Type of Fluid Additions Amount 07.00 a.m. Put up Gone in 2.00 p.m. Remainder Total at end of shift TIME INTAKE (ml) OUTPUT (ml) AFTERNOON SYIFT Method Site Urine N/G Aspirate Drains Stoma etc. Stool B.O. Type of Fluid Additions Amount 02.00 p.m. Put up Gone in 9.00 p.m. Remainder Total at end of shift TIME INTAKE OUTPUT NIGHT SHIFT Method Site Urine N/G Aspirate Drains Stoma etc. Stool B.O. Type of Fluid Additions Amount 09.00 p.m. Put up Gone in 7.00 a.m. Remainder Total at end of shift NOTES SHIFT TOTAL (ml) 24 HOUR BALANCE (ml) Morning Intake From To Output Date Date Time Time Afternoon Shift Intake Total Intake Output Total Output Night Intake Output Difference
intake-output-chart.docx