Iv Therapy Accomplished Requirements (short Bond Paper Size)

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

Name of Hospital Offering I V Training Address Accomplished Requirements of: Name of Registered Nurse:

PRC No.

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

Expiry Date:

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

I. Initiating & Maintaining Peripheral I V Infusions 1. 2. 3. 4. 5. 6. II. Administering I V Drugs

Drug Incorporated/ Dose

Date / Time / Diagnosis

1. 2. 3. 4. 5. 6. III. Administering & Maintaining Blood & Blood Components Blood Type / Volume / Components

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

1. 2. Th is is to ce rt if y t ha t I h ad su cce ssf u lly pe rf o rm ed t he ab o ve re qu irem e nt s, as cou n te rsi gn ed b y m y wit n e sse s. Received by: ____________________________________________ ANSAP

Submitted by: _____________________________________________ Signature over Printed Name of RN

I V Therapy Certification Card No. _____________________________

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.