NG Tube Maintenance Log Form
Document routine nasogastric tube care, maintenance activities, and follow-up needs.
Date and Time of Maintenance
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Initials or ID (non-sensitive)
*
Staff Name/Initials
*
NG Tube Type and Size
*
Please Select
Salem Sump
Levin
Other
Tube Insertion Site Assessment
*
Clean, dry, intact
Redness/irritation
Discharge
Other
Tube Position/Length at Nare (cm)
*
Tube Patency Check
*
Patent
Blocked
Feeding/Flush Administered
*
Feeding
Flush
Volume and Type of Feed/Flush (mL and solution)
*
Complications or Follow-Up Needed
Submit Log
Should be Empty: