Intake + Output = Big Documentation Problems

Water Hydration Input Output

By Nancy Collins, PhD, RDN, LDN, NWCC, FAND

Inaccurate and incomplete intake and output records pose a problem in litigation as well as a risk to the patient who requires monitoring of fluid balance for medical reasons. 

“Would you agree that the nurses did not know how to do basic arithmetic?” Of course nurses know how to add and subtract but yet I was being asked this question in a very challenging manner by a plaintiff attorney. He had just showed me three weeks of Intake and Output (I & O) tables excerpted from the medical chart of the deceased plaintiff and almost every shift was incomplete. The plaintiff attorney was reducing the problem to poor math skills implying that not a single day was complete because the nurses who cared for this patient lacked the abilities to add a column of numbers. He knew I would disagree because I was not going to say these nurses lacked basic math skills. But he also knew his follow up question was the real reason for this math ploy. “Okay, if it is not lack of math skills, then please tell me why the nurses did not bother to accurately complete the I & O’s on any single day of this gentleman’s hospitalization.” This line of questioning then proposes several possible explanations: the nurses were understaffed and had no time to do it. The nurses did not feel it was important. The nurses did not follow doctor’s orders as required. And on and on. None of these possibilities bode well for a favorable defense outcome. Of course this was hardly the first time I saw incomplete I & O charts. It seems that this particular record keeping task is a problem in almost every case I review and exasperates every nurse I speak with. As a profession, we need to get to the bottom of this problem.

Fluid Balance

I & O’s are ordered to measure a patient’s fluid balance. Maintaining an appropriate fluid balance is critical to health and well-being. Heart, lungs and kidneys all depend on this to function properly. If a patient becomes fluid overloaded, heart failure may result. If a patient becomes extremely dehydrated, renal failure may ensue. It is truly a balancing act. The order for I & O’s is one way to monitor if we are achieving this delicate balance. This information should be evaluated along with pulse rate, body temperature, capillary refill time, skin turgor, body weight, the presence of edema, and blood chemistries. In addition fluid balance can be affected by vomiting, diarrhea, perspiration, ostomy output, wound drains, chest drains, and more. The I & O’s are only one piece of the puzzle but if they are ordered it is expected that they will be completed properly every day.

To Order or Not to Order?

The switch to electronic health records (EHRs) has brought with it both pluses and minuses. Depending on the size of the institution, the EHR contains dozens to hundreds of order sets. An order set is a standardized list of orders for a specific diagnosis designed to be used together (different than an order pick list, which is designed to be used apart). These order sets often include I & O’s routinely. Perhaps not every single patient with a certain diagnosis truly requires I & O’s. Are we creating additional work where there is no benefit to the patient by including I & O’s in too many order sets? For example, if a patient is incontinent of urine and does not have a Foley catheter, how much information will you be able to garner from the I & O’s? You may be able to evaluate the intake but unless you are weighing wet undergarments and bedding, you will have very little accurate quantitative information to evaluate the output. The purpose of I & O’s is to total the time period in question (typically 24 hours) and then evaluate the difference between what went in and what came out to determine if there is a problem. Patients with urine incontinence make this evaluation difficult if not impossible. These patients can and should be closely monitored by other means such as such body weight, blood chemistries, and the others indicators mentioned above. It is risky business to carry a physician’s order but not execute it. The number one priority should be the patient and only the care team on site can determine if fluid balance is a true concern and if it is, how best to monitor it so that any signs of trouble can be dealt with immediately. If I & O’s are not a useful way, discontinue the order.

The I & O Challenge The ongoing problem with obtaining accurate and complete I & O’s is a serious issue that needs to be dealt with today. Your challenge is to review five charts with orders for I & O’s and see if they are indeed accurate and complete. If they are not, I hope you will begin a discussion on how to improve the process in your institution. Together we can solve this problem. Please let me know your ideas and solutions at