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

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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