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Name of Registered Nurse: Edward D. Wong Name of Hospital offering I V Training: St. Dominic Medical Center Date of I V Training Program Attended: September 16-18, 2011 I. Initiating/ Maintaining Peripheral IV Infusion s
Patient No. Kind of Infusion Type of Cannula Signature over Printed name of Certified Trainer/Preceptor/RN
PRC No. 0714828 Provider No.: 080 Venue: St. Dominic College of Asia
Name of Patient
Age
Date
Time
Site
Left Metacarpal Right Metacarpal Left Cephalic
Dose
Rate
License No.
3 84 85
Dose
Diagnosis
License No.
75 75 13
CAP t/c Musculoskeletal Strain 9/28/11 8:00 am Furosemide 40 mg CAP t/c Musculoskeletal Strain 9/28/11 9:00 am Cefuroxime 750 mg Benzyl t/c PTB, malnutrition 9/28/11 12:00pm 1 million U Penicillin t/c electrolyte imbalance
Name of Patient
Age
Date
Time
License No.
83740
Lilia Macatangay
79
10/17/11 2:40 pm
09-00523
Submitted by:____________________Date Submitted:__________Received by:_________________Approved by: Hazel N. Villagracia, RN, MAN, EdD