G-Tube Residual Check Form
Log and document each gastrostomy tube residual check for clinical care.
Patient Identifier (Initials or Medical Record Number)
*
Date of Check
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Check
*
Hour Minutes
AM
PM
AM/PM Option
Tube/Feeding Route Details
*
Residual Volume Amount
*
Residual Unit
*
Please Select
mL
cc
Other
Action Taken Based on Residual Result
*
Please Select
Proceed with feeding
Hold feeding
Re-check in 30 minutes
Notify provider
Other
Feeding/Flush Decision
*
Please Select
Feeding given
Feeding held
Flush given
No flush
Other
Symptoms or Observations
Staff Member Completing Log
*
Submit
Should be Empty: