Iv Therapy Accomplished Requirements Form

I V THERAPY ACCOMPLISHED REQUIREMENTS Venue: ____ Province/Region: ANSAP Chapter: _____________________

Name of Hospital Offering I V Training Address A cco m p lish ed R eq u ir em en t s o f: Name of Registered Nurse: Date of I V Training Program Attended: Registration No. of Institution Offering the I V Training Program: __________ Name of Patient

Age

Kind of IV Infusion given

I. Initiating & Maintaining Peripheral I V Infusions 1. 2. 3. 4. 5. 6. Drug Incorporated/ II. Administering I V Drugs Dose 1. 2. 3. 4. 5. 6. III. Administering & Maintaining Blood & Blood Components Blood Type / Volume / Components 1. 2.

PRC No. _______ Expiry Date: ___________ I V Requirements: 6+6+2 Date / Time / Site of I V Insertion Type of Cannula / Dose / Rate / Drug Incorporation present

Signature of Witness M.D./I V Trained Preceptor

Date / Time / Diagnosis

Date / Time / Site of I V Insertions Type of Cannula / Rate

This is to certify that I had successfully performed the above requirements, as countersigned by my witnesses. Received by: ____________________________________________ ANSAP

I V Therapy Certification Card No. _____________________________

Submitted by: _____________________________________________ Signature over Printed Name of RN

Approved by: ______________________________________________ Director, Nursing Service

Issued by: ____________________ Date: ______________________ Date Submitted: ____________________________________________ Note: To be submitted in duplicate to the ANSAP office within six (6) Months after Training.