iv therapy accomplished requirements 3+3+2 _long bond pape…

IVT FORM 09 s 09

3+3+2 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse: ____________________________________________ PRC No.

Name of Hospital offering I V Training: __________________________________ Provider No.: __________________________

Date of I V Training Program Attended: ______ Venue: _______________________________

I. Initiating/ Maintaining Peripheral IV Infusions

Patient

No. Name of Patient Age Date Time

Kind of

Infusion Site

Type of

Cannula Dose Rate

Signature over Printed name of

Certified Trainer/Preceptor/M.D., RN License No.

II. Administering Intravenous Drugs

Patient

No. Name of Patient Age Date Time

Kind of

Infusion Site

Type of

Cannula Dose Rate

Signature over Printed name of

Certified Trainer/Preceptor/M.D., RN License No.

III. Administering and Maintaining Blood and Blood Components

Patient

No. Name of Patient Age Date Time

Kind of

Infusion Site

Type of

Cannula Dose Rate

Signature over Printed name of

Certified Trainer/Preceptor/M.D., RN License No.

Submitted by:____________________Date Submitted:__________Received by:__________________Approved by: _______________________

(Signature over Printed Name) Director of Nursing Service

(Signature over Printed Name)