IV THERAPY ACCOMPLISHED REQUIREMENTS FORMAT

______________________________ Venue:
Name of Hospital Offering IV Training Province/ Region:
______________________________ ANSAP Chapter:
Address
Accomplished Requirements of
Name of Registered Nurse: PRC No.: Expiry Date:
Date of IV Training Program Attended: IV Requirements: 6+6+2
Registration No. of Institution Offering the IV Training:
Date/ Time/ Site of IV Insertion Signature of Witness
Kind of IV Infusion
Name of Patient Age Type of Cannula/ Dose/ Rate/ Drug Incorporation M.D./IV Trained
given
Present Preceptor
I. Initiating Maintaining Peripheral IV Infusions
1.
2.
3.
4.
5.
6.
II. Administering IV Drugs Date/ Time/ Drug Incorporated/
Dose/ Diagnosis
1.
2.
3.
4.
5.
6.
III. Administering & Maintaining Blood & Blood Components
Blood Type/
Date/ Time/ Site of IV Insertions
Volume/
Type of Cannula/ Rate
Component
1.
2.
This is to certify that I had successfully performed the above requirements, as countersigned by my witnesses.
Received by:__________________________________ Submitted by:_____________________________________
ANSAP Signature over Printed Name of RN
IV Therapy Certification Card No.________________________ Approved by:_____________________________________
Director, Nursing Service
Issued by:_____________________ Date:_________________ Date Submitted:___________________________________
Note:To be submitted to the ANSAP office within six (6) months after Training.