. DOLLEZON PRC Number: ________________________________ Name of Hospital offering IV Training: ___________________________________________________________ Provider No. _______________256_______________ Date of IV Training Program Attended: ____________________________________________________ Venue: _____________________________________ I. Patien t No. 11014 3 11017 7 11018 7 II. Patie nt No. 11016 8 11014 3 11017 9 Initiating / Maintaining Peripheral IV Infusions Name of Patient Age Date Time Kind of Infusion Danas, Joshua Villarimo, Rienz Cabili, Cesaria 8mo s. 4 y.o. 71 y.o. 05/06/ 13 05/06/ 13 05/07/ 13 08:00 AM 09:00 AM 09:10 AM D5IMB PNSS D5LR Site Type of Cannul a ONC G24 ONC G24 ONC G22 Dose Rate Signature over Printed Name of Certified Trainer/Preceptor/M.D.,RN Ms. Lerma R. Cabagui, RN Ms. Lerma R. Cabagui, RN Ms. Lerma R. Cabagui, RN Licen se No. 080145 66 080145 66 080145 66 Licens e No. 0711198 0711198 0711198
Administering Intravenous Drugs Name of Patient Age Date Langaylangay, Kylna Danas, Joshua Aque, Neil 3 y.o. 8 mos. 36 y.o. 05/06/ 13 05/06/ 13 05/07/ 13
Drugs Incorporated D5IMB (500cc) 50cc in soluset + Amikacin 100mg @30ugtts/min D5IMB (500cc) 50cc in soluset + PEN G 400,000 u D5NM (500cc) 50cc in soluset + cefuroxime 750mg @kvo
Dose 100mg
Diagnosis Duengue Fever Syndrome CAP Moderate Risk Community Acquired Pneumonia Moderate Risk PTB III
Signature over Printed Name of Certified Trainer/Preceptor/M.D.,RN Ms. Julie Ann D. Saplot, RN
400,00 0 u 750mg
Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION) Name of Patient Age Date Tim Volume / Blood IV Type Diagnosis Signature over Printed e Type/Components Inserti of Name of Certified /Rate on Cannul Trainer/Preceptor/M.D.,RN a Erederos, Vicente 78y. 05/06/ 06:0 450CC/B+/; unit Left G-18 Severe Ms. Julie Ann D. Saplot, RN o. 13 0PM FWB/30gtts/min Cephal ONC anemia ic Vein secondary to acute myelodysplas ia Date submitted: _________________ Received by: ___________________
Submitted by: _________________________________________ MARIAM V. DEANG RN, MAN Signature over Printed Name Director of Nursing Services (Signature over Printed name)
Approved by: