3+3+1 ACCOMPLISHED REQUIREMENTS of 3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES Name of Registered Nurse : JAN

N ALLYSA B. MARVIDA__________________ 08/06/2012 Name of Hospital Offering IV Training : BICOL MEDICAL CENTER, Naga City, 4400________ Date of IV Training Program Attended : JUNE 1-3, 2011______________________________ I. Initiating/ Maintaining Peripheral IV Infusions
Patient No. Name of Patient Age Date Time Kind of Infusion Site of IV Insertion Type of Cannula Dose Rate Signature Over Printed Name of Certified Trainer / Preceptor License no.

PRC Number/ Expiry Date Provider Number Venue

: 0585085 /

: 109______________________ : BMC Auditorium__________

1 2 3 II. Administering Intravenous Drugs

Patient No. Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis Signature Over Printed Name of Certified Trainer / Preceptor License no.

1 2 3 III. Asministering and Maintaining Blood and Blood Components

Patient No. Name of Patient Age Date Time Volume/ Blood Type/ Component/ Rate Site of IV Insertion Type of Cannula Signature Over Printed Name of Certified Trainer / Preceptor License no.

Diagnosis

1 Submitted By : _________________________________
Signature over printed name of RN

Date Submitted : _________________________________

Approved by: AMELIA V. ENRIQUEZ . R.N., M.A.N. IV Trainer/ Chief Nurse Received by : _________________________________