Patient:____________ Patient:____________ Patient:____________

Patient:____________
I & O: I & O: I & O:
I & O:
Received from endorsement: ___ mL Received from endorsement: ___ mL Received from endorsement: ___ mL
Received from endorsement: ___ mL
Actual amount received drg. Rounds: ___ mL Actual amount received drg. Rounds: ___ mL Actual amount received drg. Rounds: ___ mL
Actual amount received drg. Rounds: ___ mL
Drop rate:_____ cc/hr or gtts/min Drop rate:_____ cc/hr or gtts/min Drop rate:_____ cc/hr or gtts/min
Drop rate:_____ cc/hr or gtts/min
Time tape: Time tape: Time tape:
Time tape:
Amt. Amt. Amt.
Amt.
in in in
in
mL mL mL
mL
8am 8am 8am
8am
9am 9am 9am
9am
10am 10am 10am
10am
11am 11am 11am
11am
12nn Oral Parenteral Total 12nn Oral Parenteral Total 12nn Oral Parenteral Total
12nn Oral Parenteral Total
1pm 1pm 1pm
1pm
2pm Urine Others Total 2pm Urine Others Total 2pm Urine Others Total
2pm Urine Others Total
3pm 3pm 3pm
3pm

Oxygen: Oxygen: Oxygen:

Received from endorsement: _____
Remaining O2 ____ Consumed O2 ____
Oxygen:
Received from endorsement: _____ Received from endorsement: _____
Received from endorsement: _____
Remaining O2 ____ Consumed O2 ____ Remaining O2 ____ Consumed O2 ____
Remaining O2 ____ Consumed O2 ____

Patient:____________ Patient:____________ Patient:____________ Patient:____________

I & O: I & O: I & O: I & O:
Received from endorsement: ___ mL Received from endorsement: ___ mL Received from endorsement: ___ mL Received from endorsement: ___ mL
Actual amount received drg. Rounds: ___ mL Actual amount received drg. Rounds: ___ mL Actual amount received drg. Rounds: ___ mL Actual amount received drg. Rounds: ___ mL
Drop rate:_____ cc/hr or gtts/min Drop rate:_____ cc/hr or gtts/min Drop rate:_____ cc/hr or gtts/min Drop rate:_____ cc/hr or gtts/min
Time tape: Time tape: Time tape: Time tape:
Amt. Amt. Amt. Amt.
in in in in
mL mL mL mL
8am 8am 8am 8am
9am 9am 9am 9am
10am 10am 10am 10am
11am 11am 11am 11am
12nn Oral Parenteral Total 12nn Oral Parenteral Total 12nn Oral Parenteral Total 12nn Oral Parenteral Total
1pm 1pm 1pm 1pm
2pm Urine Others Total 2pm Urine Others Total 2pm Urine Others Total 2pm Urine Others Total
3pm 3pm 3pm 3pm

Oxygen: Oxygen: Oxygen: Oxygen:

Received from endorsement: _____ Received from endorsement: _____ Received from endorsement: _____ Received from endorsement: _____
Remaining O2 ____ Consumed O2 ____ Remaining O2 ____ Consumed O2 ____ Remaining O2 ____ Consumed O2 ____ Remaining O2 ____ Consumed O2 ____