INTAKE AND OUTPUT
Medical Dx: STROKE IN EVOLUTION Shift: 7am – 3pm
7 am – IVF of D5W 1LxKVO on @680cc
8am – OF via NGT 250cc
9am – FC with 150cc
10am – Mannitol 100cc
11:30am – flush 150mL of water prior to feeding
2pm – OF 250mL via NGT
2:15pm – voided 2x w/diaper
Republic of the Philippines
Province of Nueva Ecija
EDUARDO L. JOSON MEMORIAL HOSPITAL
(NUEVA ECIJA PROVINCIAL HOSPITAL)
Daan Sarile, Cabanatuan City
INTAKE AND OUTPUT CHART
PATIENT:________________ _______ WARD__________ BED NO.________ TIME______ to ______
TIME ORAL IV SIGNATURE GASTRIC URINE STOOL VOMITUS OTHERS SIGNATUR
7-8 Kate Quiban
8-9 250mL WUP-SN’22
9-10 Kate Quiban 150mL Kate Quiban
10-11 WUP-SN’22 WUP-SN’22
11-12 150mL 240mL Kate Quiban
12-1 SD: 100mL WUP-SN’22
1-2 Kate Quiban Kate Quiban
2-3 250mL WUP-SN’22 2X WUP-SN’22
8hrs. 650mL 340mL Kate Quiban 150mL 2X Kate Quiban
Total WUP-SN’22 WUP-SN’22
3-4
4-5
5-6
6-7
7-8
8-9
9-10
10-11
8hrs
Total
11-12
12-1
1-2
2-3
3-4
4-5
5-6
6-7
8hrs
Total
24hrs
Total
Total Intake__________________________________ Total Output______________________________
BY__________________________________________ Date__________________ Time______________
ENDORSEMENT
203, B. Frederico Inzacruz/ Dra. Gomez
Dx: DF, Acute Gastritis, Arthritis, HPN II