Intake & Output (I&O) Documentation Example
Intake and output documentation records measured fluids taken in and fluids lost over a set period, usually on a flowsheet.
Educational use & privacy
Educational documentation practice only. Use fictional or instructor-provided information. Do not enter real patient information or protected health information (PHI). Documentation requirements vary by organization, setting, role, policy, and applicable law.
Nursing Notes Privacy & SafetyContent status: Draft — not yet professionally reviewed.
Why it is structured this way
I&O records are only useful when measurements are specific and totals are correct. Estimated or missing entries make trends impossible to interpret.
When this may be used
- When ordered or required by policy.
- Time periods (per shift, per 24 hours) vary by facility.
- Documentation requirements, frequency and screens vary by organization, setting and EHR. Follow your program's and facility's policy.
Components
Intake
Fluids in.
What belongs here
- Oral, IV, tube feeding and flushes, in mL
What does not belong
- Unmeasured guesses written as exact
Output
Fluids out.
What belongs here
- Urine, emesis, drains, in mL
What does not belong
- "Voided" with no amount when measurement is ordered
Totals and period
Summary.
What belongs here
- Totals for the defined period
What does not belong
- Totals from another period
Short fictional example
- Intake
- Oral 720 mL; IV 600 mL. Total 1,320 mL.
- Output
- Urine 950 mL. Total 950 mL.
More detailed fictional example
- Intake
- Oral 480 mL; IV normal saline 800 mL (100 mL/h × 8 h per order). Total intake 1,280 mL.
- Output
- Urine by catheter 900 mL; surgical drain 60 mL serosanguineous. Total output 960 mL.
- Note
- Balance for the period: intake exceeded output by 320 mL.
Annotated example
Notes on the detailed example above:
(100 mL/h × 8 h per order)
— IV intake is traceable to a rate and time.Total intake 1,280 mL
— 480 + 800 = 1,280; 900 + 60 = 960; 1,280 − 960 = 320.
Common mistakes
- Adding values from different time periods.
- Forgetting IV flushes or piggybacks per policy.
- Documenting "voided" with no amount when I&O is ordered.
Good vs poor documentation
Weaker (fictional)
Drank a lot, peed OK.
Stronger (fictional)
Oral intake 720 mL; urine output 950 mL (0700–1500).
Why: Measured values and time period.
Blank educational template
Shift summary: A concise summary of the shift. Prompts only; nothing is prefilled.
- Overall status
- [Summary of findings across the shift]
- Key events
- [Significant events with times]
- Care provided
- [Main interventions performed]
- Responses
- [Responses and reassessments]
- Pending items
- [Follow-up items for the next nurse]
Practice this format
Related documentation guides
- IV site assessment
- End-of-shift note
- Charting by exception
- Nursing Unit Converter — Convert fluid units.
- Infusion Time Calculator — Volume, rate and time math.
Sources
- ANA's Principles for Nursing Documentation (2010) — American Nurses Association.
- Nursing Fundamentals 2e — 2.5 Documentation — Open RN (Chippewa Valley Technical College).
- Fundamentals of Nursing — 14.5 Guidelines for Effective Documentation — OpenStax.
All examples on this page are original and fictional. Sources are used to check principles; they do not endorse Dosage Calcs. See Privacy & Safety.