IVT FROM 09 s 09

3+3+1 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES
Name of Registered Nurse
Name of Hospital offering IV Training
Date of IV Training Program Attended
Multipurpose Hall

I.

Name of Patient

_____________________________
Provider Number ___145___
Venue: St. Paul Hospital Tuguegarao

Age

Date

Time

Kind of
Infusion

Site

Time

Drugs
Incorporated

Dose

Type of
Cannul
a

Dose

Rate

License
No.

Signature over Printed name

of Certified Trainer/Preceptor

Administering Intravenous Drugs

Patient
No.

III.

PRC Number

Initiating/ Maintaining Peripheral Infusions

Patient
No.

II.

_____________________________
St. Paul Hospital of Tuguegarao, Inc.
February 25 27, 2015

Name of Patient

Age

Date

Diagnosis

Signature over Printed name

of Certified Trainer/Preceptor

License
No.

Administering and Maintaining Blood and Blood Components

Patient
No.

Name of Patient

Age

Date

Time

Volume/Blood
type/Compone
nt/Rate

IV
Insertio
n

Type of
Cannul
a

Diagnosis

Signature over Printed name

of Certified Trainer/Preceptor

License No.

Submitted by: _____________________ Date Submitted: __________ Received By: ________________Approved by: SR. ROWENA C. RODIL, SPC
(Signature over Printed Name)

Director of

Nursing Service
(Signature over Printed
Name)