Intake and Output Activity

Complete the intake and output chart sample. Use the following information:

Breakfast cream of wheat cereal 250 ml

coffee 150 ml
Juice 100 ml
toast

Lunch soup 200 ml

sandwich
milk 150 ml
Juice 75 ml

Supper tea 250 ml

turkey tetrazzini
pudding 300 ml

Bedtime snack 1ce cream 200 ml

Output
Urine 0830 300 ml
1230 300 ml
1730 300 ml

Emesis 1600 200 ml

Diarrhea 0100 400 ml

 Patient's Name (addressograph)

CLINICAL RECORD
INTAKE AND OUTPUT RECORD

INTAKE OUTPUT
DATE SHIFT

ORAL IV TUBE OTHER TOTAL URINE STOOL VOMITUS DRAINS OTHER TOTAL

24HR. TOTAL

24HR. TOTAL

24HR. TOTAL

24HR. TOTAL

Enter total INTAKE and OUTPUT at end of each shift and grand total for each 24 hour period