Palm Beach State College –Simulation Medical Unit
Intake / Output Record
Date: _______________________________________	Student Name: __________________________________
INTAKE	OUTPUT	
TIME	ORAL	ENTERAL	IV MEDS/FLUSHES	IVF	OTHER	TOTAL	URINE	EMESIS	STOOL	OTHER	TOTAL	
0000												
0100												
0200												
0300												
0400												
0500												
0600												
0700												
0800												
0900												
1000												
1100												
1200												
1300												
1400												
1500												
1600												
1700												
1800												
1900												
2000												
2100												
2200												
2300												
DAILY TOTAL												

NAME: Jones, Charles    					MR# 342397
ALLERGIES: NKDA						ROOM: ________347_____________
DIAGNOSIS: SOB R/O Decompensated CHF                        ADMITTED: 	___08/30/10/______________
PHYSICIAN: Dr. Mitchell                                                   GENDER:Male
DOB: 02/19/1942		Age: 68          Height: 72 inches      Weight: 180 lbs.