3+3+1 ACCOMPLISHED REQUIREMENTS of

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES

Name of Registered Nurse KEVIN DAVIDSON RAYOS ADVIENTO PRC Number 0827274
Name of Hospital offering IV Training _______________________________________ Provider No. _________________________________________
Date of IV Training Program Attended______________________________________ Venue ______________________________________________

I. Initiating/ Maintaining Peripheral IV Infusion
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.,
R.N.
License
No.
4079 Charlounico Tejada Calpatura 14 4/1/2014 11:10am D5LRS R Metacarpal
Vein
Gauge 22 1L KVO Vilma M. Marquez RN, MAN CHLC297
3661 Juan Quezon 92 4/1/2014 12:00Nn D5LRS R Metacarpal
Vein
Gauge 22 1L 10 gtts/min Vilma M. Marquez RN, MAN CHLC297
3946 Jun Panio 48 4/1/2014 2:00pm D5LRS R Metacarpal
Vein
Gauge 22 1L 21gtts/min Vilma M. Marquez RN, MAN CHLC297

II. Administering Intravenous Drugs
Patient
No.
Name of Patient Age Date Time Drugs
Incorporated
Dose Diagnosis Signature over Printed Name of
Certified Trainer/ Preceptor/ M.D.,
R.N.
License
No.
3987 Juan Baylon Acpal 92 4/1/2014 9:00am Omeprazole 40mg OD HPN II, Malnutrition, PUC, t/c CAP Vilma M. Marquez RN, MAN CHLC297
3953 Milagros Belon 42 4/1/2014 9:15am Hydrocortisone 100mg OD Bronchial Asthma in Acute
Exacerbation
Vilma M. Marquez RN, MAN CHLC297
3919 Knechtel Luna 24 4/1/2014 9:35am Hydrocortisone 100mg Bronchial Asthma in Acute
Exacerbation
Vilma M. Marquez RN, MAN CHLC297

III. Administering and Maintaining Blood and Blood Components (2 NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)
Patient No. 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/ M.D.,
R.N.
License
No.
3425 Andres Madiam 85 4/1/20
14
10:00a
m
450cc/ A/ PRBC/ 28
gtts/min
R Metacarpal
Vein
Gauge 18 Prostate CA Vilma M. Marquez RN, MAN CHLC297

Submitted by: KEVIN DAVIDSON R. ADVIENTO Date Submitted: APRIL 02, 2014 Received by: REYNIER PAUL F. DUMALE, RN Approved by: ARMIE H. GARCIA RN, MSN
Signature over Printed Name Director of Nursing Service
(Signature over Printed Name)