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VITAL SIGNS

INTAKE & OUTPUT SHEET


HOSPITAL #:

PATIENT’S NAME: Mr. dela Cruz AGE: 67 SEX: M CIVIL STATUS: WARD: Medical ICU

VITAL SIGNS INTAKE OUTPUT


DATE TIME NGT
BP TEMP CR RR IV PO NGT TOTAL URINE STOOL TOTAL
VOMITUS
6/13/18 8 AM - - - - 2 mL of - OTF & H20- - - - -
Furosemide 250 mL
40 mg
10 AM - - - - - - - - 350 mL - -
12 NN - - - - 5 mL - OTF & H20- - 250 mL - -
Antibiotic 250 mL
2 PM - - - - - - - - 200 mL - -
PNSS – 400 - - - - - -
mL
407 mL - 500 mL 907 mL 800 mL - - 800 mL

6hrs Retention: 107 mL

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