HOSPITAL LOGO NAME: DATE:

UHID NO: AGE: SEX:

ICU FLOW SHEET BED NO:
CONSULTANT DR:

INTAKE: TOTAL INPUT: OUTPUT: TOTAL OUTPUT: IV:______________ UOP:_______________________ Drains:__________________

8AM/2PM__________ 8AM/2PM__________ RTF:_____________ RTA:_______________________ Stool:___________________

2PM/8PM__________ 2PM/8PM__________
8PM/8AM___________ 8PM/8AM__________ Oral:_____________
Antimicrobials Sr Medication Day Dose Route Freq Remarks Time M MD E N Infusion & IV fluids
No

PPI

STAT ORDER
Others

Investigation Results Informed to

Reports Pending:

Diet Order:_________________________________________ Time 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12pm 1am 2am 3am 4am 5am 6am 7am
Mg/dl
Special Instruction:___________________________________
Insulin
Name & Sign : RMO: _________________________________ IV/SC
Given
Consultant Sign:____________________________________ By
 HOSPITAL LOGO NAME: DATE:
UHID NO: AGE: SEX:
ICU FLOW SHEET BED NO:
CONSULTANT DR:

V Time 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm 12am 1am 2am 3am 4am 5am 6am 7am 24hr I/O (previous Day)
I Position Oral
T
Temp. IV
A
L HR RT
P RR
A BP Total Intake=
R MAP Urine
A
CVP RTA
M
E SpO2 Drains
T GCS
E AG Total Output=
R
I/O Balance
S
V Mode
E VT Haemodialysis Details
T
PEEP Started at
I
L PS Terminated at
A Freq. Hours
T FiO2 UF
O
I.E
R
Peak Pressure Bowel Movements
IV Frequency
F
L Color
U
I
D Consistency
S
I
N Indwelling catheter Days
I F
N U
ETT/Tracheo
T S Central Line
A I Arterial Line
K O Foley’s
E N
RT
B Drains(1)
O Drains(2)
L
U
Venti Days
S Dialysis catheter
NUTRITION ORAL
TUBE Name of Staff Sign
Hourly Intake RMO
Total Intake M
Urine Output E
O RT Aspirate N
U
Drains(1) Nursing
T
P Drains(2) M
U Stool/Stoma E
T Total Output N