NPO INTAKE AND CLARIFICATION RECORD
Record the treating team’s confirmed instructions and actual intake separately.

PATIENT AND CURRENT PLAN
Patient identifiers:
Procedure / date:
Arrival time / expected procedure time:
Reason for oral-intake restriction:
Active order or preparation-plan reference / author / date:
Food cutoff date and time:
Permitted fluids / cutoff date and time:
Start of nothing-by-mouth period / date and time:
Medication exceptions / dose / time / permitted water / confirming clinician:
Other preparation instructions:
Patient's explanation of the instructions:

ACTUAL INTAKE HISTORY
Interview date and time / interviewer:
Last food / type / amount / date and time finished:
Last drink / type / amount / date and time finished:
Additions such as milk or creamer / amount:
Oral medicines taken / dose / liquid used / date and time:
Other oral intake, including gum, if relevant:
Source of each report / directly observed intake:
Uncertain or conflicting details:

CLARIFICATION AND CLINICAL REVIEW
Difference between instructions and intake history:
New or corrected history / source / time obtained:
Original entry reference / correction-history location:
Responsible clinician contacted / time / information sent:
Acknowledgment received / time:
Review accepted by / agreed checkpoint:
Clinical decision / authorized by / date and time:
Revised procedure plan / confirmed or still pending:
Updated oral-intake and medication instructions / source:
Instructions explained to patient / understanding checked:

FOLLOW-UP AND SAVED-RECORD CHECK
Unresolved task / responsible person / next checkpoint:
Action if no response by checkpoint:
Structured intake fields checked against narrative / checked by:
Authorization to resume intake, if given / source / time:
Actual intake after authorization / source / time:
Event time / entry time / author / authentication: