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3+3+1 ACCOMPLISHED REQUIREMENT of DAYS BASIC IV THERAPY TRAINING PROGRAM for NURSES Name of Registered Nurse: Name of Hospital

l Offering IV Training: Date of I V Training Program Attended:


MA. FATIMA DELOS SATOS

SAMPLE ONLY USE the other one below


14343324 094 SPCMC Conference Room

San Pablo Colleges Medical Center, San Pablo City, LAGUNA May 23-25, 2009

PRC Number: Provider No: Venue:

I: Initiating / Maintaining Peripheral IV Infusions


Patient No:

Name of Patient

Age 22y/o 48y/o

Date 2-28-10 3-04-10 3-05-10

Time 11:00am 8:50am 6:00pm

Kinds of fusions

Site L Metacarpal vein L Metacarpal Vein R Cephalic Vein

Type of Cannula

Dose 1L x 8hrs 1L x 16hrs 1L x 12hrs

Rate 42gtts/min 21gtts/min 83mgtts/min

Signature over Printed Name of Certified Trainer/Preceptor

License No:

1. 2. 3. Pedia case

D5LRS D5LRS D5LRS

G:20 G:20 G:22

Use 20 as drop factor


ROWENA P. BATI ROWENA P. BATI AN: 003993 AN: 003993

12y/o

II.
Patient No:

Administering Intravenous Drugs


Name of Patient Age y/o y/o y/o Date 3-05-10 3-05-10 3-05-10 Time 8:00pm 9:00pm 10:00pm
Drugs Incorporated Dose

Diagnosis t/c Gastritis r/o Cholelithiasis Upper Gstro Int. Bleeding

Signature over Printed Name of Certified Trainer/Preceptor


BERNARDO ALIMAGNO JR. BERNARDO ALIMAGNO JR. BERNARDO ALIMAGNO JR.

License No:
AN: 07-7116 AN: 07-7116 AN: 07-7116

1. 2. 3.

Ranitidine 50mg ampule Cefurozime 750mg vial Ranitidine 50mg ampule

1 amp IV q 12hrs 750mgIV q 8hrs 1 amp IV q 8hrs

III. Administering & Maintaining Blood and Blood Components


Patient No:

Name of Patient

Age y/o

Date 3-06-10

Time 8:00am

Volume/Blood Type Components/Rate

IV Insertion

1.
Submitted by

Type O Rh(+) 250 PRBC x21gtts

LMetacarpal Vein

Type of Cannula G:20

Diagnosis UGIB

Signature over Printed Name of Certified Trainer/Preceptor


BERNARDO ALIMAGNO JR.

License No:
AN: 07-7116

500cc FWB x 42gtts


MA. FATIMA DELOS SANTOS

Date Submitted:

March 17, 2010

Received by:

Approved by:

PROF. CLEOFE A. CABRERA Director, Nursing Service (Signature over printed Name)

(Signature over printed Name)

3+3+1 ACCOMPLISHED REQUIREMENT of DAYS BASIC IV THERAPY TRAINING PROGRAM for NURSES Name of Registered Nurse: Name of Hospital Offering IV Training: Date of I V Training Program Attended:

San Pablo Colleges Medical Center, San Pablo City, LAGUNA February 21 23, 2013

PRC Number: Provider No: Venue:

155 SPCMC Conference Room

I: Initiating / Maintaining Peripheral IV Infusions


Patient No:

Name of Patient

Age

Date

Time

Kinds of Infusions

Site

Type of Cannula

Dose

Rate

Signature over Printed Name of Certified Trainer/Preceptor


ROWENA P. BATI ROWENA P. BATI ROWENA P. BATI

License No:
AN: 003993 AN: 003993 AN: 003993

1. 2. 3.

II.
Patient No:

Administering Intravenous Drugs


Name of Patient Age Date Time
Drugs Incorporated Dose

Diagnosis

Signature over Printed Name of Certified Trainer/Preceptor


BERNARDO ALIMAGNO JR. BERNARDO ALIMAGNO JR. BERNARDO ALIMAGNO JR.

License No:
AN: 077116 AN: 077116 AN: 077116

1. 2. 3.
III. Administering & Maintaining Blood and Blood Components
Patient No:

Name of Patient

Age

Date

Time

Volume/Blood Type Components/Rate

IV Insertion

Type of Cannula

Diagnosis

Signature over Printed Name of Certified Trainer/Preceptor


BERNARDO ALIMAGNO JR.

License No:
AN: 077116

1.
Submitted by
(Signature over printed Name)

Date Submitted:

Received by:

Approved by:

PROF. CLEOFE A. CABRERA Director, Nursing Service (Signature over printed Name)

PRECEPTORS ANSAP NUMBER: 1. 2. BERNARDO ALIMAGNO JR. ROWENA P. BATI AN: 077116 AN: 003993

Complete the details please

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