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Stockport NHS Foundation Trust
DAILY INTAKE AND OUTPUT CHART
Date INTAKE OUTPUT/ / Oral IV/SC Other Routes Urine Vomit Tube Other Total
Time (24hr)
Mls Fluid Mls Nature of fluid
Mls Nature of fluid
Mls Mls Mls Mls
123456789101112131415161718192021222324
24hr
Total
Name ____________________________Unit Num ___________ Ward ___________
Input from previous day ____________ Estimated fluid requirments/24hrs _________Output from previous day ____________ Estimated K requirments/24hrs _________Balance ____________ Estimated Na requirments/24hrs _________
U/E checked LVSF________ Body Weight____________ Red jug/beaker scheme Yes/No
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