Bowel Chart
Bowel Chart
Bowel Chart
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Current bowel management plan if known _________________________________________________<br />
_____________________________________________________________________________________<br />
Legend<br />
Amount<br />
A smear<br />
B < 150 mls<br />
( < small cup)<br />
C about 150 mls<br />
( = small cup)<br />
D > 150 mls<br />
( > small cup)<br />
Observations<br />
Date<br />
Time<br />
Amount<br />
Consistency - Bristol Stool Form Scale*<br />
Day Evening Night<br />
Consistency<br />
Incontinence<br />
Time<br />
Amount<br />
Consistency<br />
Incontinence<br />
Time<br />
Amount<br />
*Reproduced by kind permission of Dr KW Heaton, Reader in Medicine at the University of Bristol<br />
2000 Norgine Limited<br />
U.R. Number __________________________________<br />
Surname _____________________________________<br />
Given Names _________________________________<br />
D.O.B. / / Sex _______________<br />
Consistency<br />
Incontinence<br />
Use Label If Available<br />
Other observations may be<br />
recorded in comments column<br />
Presence of:<br />
• blood – amount, colour<br />
• mucous - amount<br />
• undigested food<br />
• fat<br />
Colour Of Stool, especially:<br />
• black or very dark stools<br />
• very pale stools<br />
Aperients,<br />
Suppositories &<br />
Enemas<br />
(Name, dose &<br />
time)<br />
Initial<br />
Comments<br />
<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
✼<br />
OBSERVATIONS BOWEL ELIMINATION MR/550.0
Date<br />
Time<br />
Amount<br />
Consistency<br />
Incontinence<br />
Time<br />
Amount<br />
Consistency<br />
Incontinence<br />
Time<br />
Amount<br />
Consistency<br />
Day Evening Night<br />
Observations<br />
Incontinence<br />
Aperients,<br />
Suppositories &<br />
Enemas<br />
(Name, dose &<br />
time)<br />
Initial<br />
Comments
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