INTRAVENOUS INSERTION

NO. : _________

CASE NUMBER:______________ DATE:______________

NAME OF PATIENT: __________________

AGE:________ B-DAY:_________SEX:________ STATUS:_________
COMPLETE ADDRESS: __________________________________________________

OBSTETRICS HISTORY:

GRAVIDA:__ G__T__P__A__L___
PARA::_____
LMP: _________ EDC:_________ AOG: ____

IV INSERTION SITE: ______________________ NAME OF SOLUTION: ____________________________

INDICATION: ___________________________________________________
COMPLETE DIGANOSIS:

_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________

DATE OF DELIVERY:_____________________ TIME OF DELIVERY:_________________

NATURE OF DELIVERY:____________________________________________
SEX OF BABY: _________________ APGAR SCORING: _________ (1ST min.) _________ ( 5th min.)
ANTROPOMETRIC MEASUREMENT(CM):
HEAD:_________CHEST:________ABDOMEN:_________HEIGHT:__________WEIGHT:________

NAME OF THE FACILITY: __________________________________________

ADDRESS OF THE FACILITY: ________________________________________

ASSISTED BY: ______________________

HANDLED BY: ______________________(name of student)
SUPERVISED BY:

__________________________ ____________________________
NURSE ON DUTY MIDWIFE ON DUTY

_____________________________
CLINICAL INSTRUCTOR

__________________________________
OR/DR SUPERVISOR