Rx Iv Therapy Accomplished Requirements(2)

Venue: Province/Region: ANSAP Chapter:

Name of Hospital Offering I V Training _____ Address A cc om plis he d Re quir e m e nts of: 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 Insertions 1. 2. 3. 4. 5. 6. II. Administering I V Drugs 1. 2. 3. 4. 5. 6. III. Administering and 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

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:

Submitted by: ANSAP

I V Therapy Certification Card No.

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.

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