IVT FORM 25 OF 26 S211

3+3+1 ACCOMPLISHED REQUIREMENTS of 3- DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse __________________________________________________________ Name of Hospital offering IV Training __________________________________________________ Date of IV Training Program Attended _________________________________________________ PRC Number __________________________________________________ Provider NO. __________________________________________________ Venue _______________________________________________________

I.
Patient No.

Initiating / Maintaining Peripheral IV infusions
Name of Patient Age Date Time Kind of Infusion Site Type of Cannula Dose Rate Signature over Printed name of Certified Trainer /Preceptor / MD, RN License No.

II.
Patient No.

Administering Intravenous Drugs
Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis Signature over Printed name of Certified Trainer / Preceptor / MD, RN License No.

III.
Patient No.

Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)
Name of Patient Age Date Time Volume/Blood Type/Components/Rate IV Insertion Type of Cannula Diagnosis Signature over Printed name of Certified Trainer / Preceptor / MD, RN License No.

Submitted by: __________________________________ Date submitted: ____________ Received by: __________________________ Approved by: ______________________
Signature over Printed Name Director of Nursing Services (Signature over Printed Name)

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