REPUBLIC OF THE PHILIPPINES

CITY OF CEBU
CEBU CITY MEDICAL CENTER

IN-HOUSE BASIC INTRAVENOUS THERAPY TRAINING
COMPLETION REQUIREMENTS

Name of Registered Nurse ________________________________________ PRC Number ___________________
Date of IV Training Program Attended ________________________________________ Venue ___________________

I. Initiating / Maintaining Peripheral IV Infusions
PIN Name of Patient Age Date Time Kind of Infusion Site Type of Cannula Rate
Signature over Printed Name of
Certified Trainer / Preceptor
License
No.










II. Administering Intravenous Drugs
PIN Name of Patient Age Date Time Drugs Incorporated Dose Diagnosis
Signature over Printed Name of
Certified Trainer / Preceptor
License
No.










III. Administering and Maintaining Blood and Blood Components
PIN 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
License
No.








Submitted by: ___________________________ Date Submitted: ___________ Received by: _______________ Approved by: _______________________________
(Signature over Printed Name) Director of Nursing Service
(Signature over Printed Name)