IVT Form

3+3+1 ACCOMPLISMENT REQUIREMENTS

3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse: DOMINGO, 1ANICE S. PRC Number:
0696478
Name of Hospital Offering IV Training: BAGUIO GENERAL HOSPITAL and MEDICAL CENTER Provider No.: 028
Date of IV Training Program Attended: December 3-5 2011 Venue: BGHMC Auditorium

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
License
No.
55473 Torres,1esie 48 December 28, 2011 10am 0.9 Sodium
Chloride
Solution
Left Metacarpal
Vein
Introcan G20 1LiterX
16 Hours
16 drops/minute Zenaida Riboroso RN,MAN 62560
445235 Agpawan,Samuel 79 December 28, 2011 1pm Dextrose 5
in Water
Left Metacarpal
Vein
Introcan G22 500LiterX
KVO
10 drops/minute Zenaida Riboroso RN,MAN 62560
043903 Banawan,Francis 54 December 28, 2011 5pm 0.9 Sodium
Chloride
Solution
Left Metacarpal
Vein
Introcan G22 1LiterX
KVO
10 drops/minute Zenaida Riboroso RN,MAN 62560

II. Administering Intravenous Drugs
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
License
No.
327324 Tachado,Editha 68 December 28, 2011 8am Sulbactam-
Ampicillin
Left Metacarpal
Vein
Introcan G20 1.5gm/ml
every 8
hours
20 drops/minute
Zenaida Riboroso RN,MAN
62560
558412 Cirineo,Desiree 39 December 28, 2011 12pm Mannitol Right Metacarpal
Vein
Introcan G24 200ml every
4 hours
31 drops/minute
Zenaida Riboroso RN,MAN
62560
593007 Hermenora,Petra 76 December 28, 2011 12pm Piperacillin+
Tazobactam
Right Metacarpal
Vein
Introcan G22 2.25gm/ml
every 6
hours
20 drops/minute Zenaida Riboroso RN,MAN 62560
III. Administering and Maintaining Blood and Blood Components
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
License
No.
485857 Andres, Decela 27 December 28,2011 2pm Type ~O(+)
Fresh Frozen
Plasma
Left Metacarpal
Vein
Introcan G18 250ml 30 drops/minute Zenaida Riboroso RN,MAN 62560
Submitted by: DOMINGO,1ANICE S. Date Submitted: February 22, 2011 Received by: 1ovita E. Pajarillo RN, MAN Approved by: Elena Tampican RN,MAN
IVT Form
3+3+1 ACCOMPLISMENT REQUIREMENTS
3-DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM for NURSES
Name of Registered Nurse: DOMINGO, 1ANICE S. PRC Number:0696478
Name of Hospital Offering IV Training: BAGUIO GENERAL HOSPITAL and MEDICAL CENTER Provider No.: 028
Date of IV Training Program Attended: December 3-5 2011 Venue: BGHMC Auditorium

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
55473 Torres,1esie 48 December 28, 2011 10am 0.9 Sodium
Chloride
Solution
Left Metacarpal
Vein
Introcan G20 1LiterX
16 Hours
16 drops/minute Zenaida Riboroso RN,MAN
62560
445235 Agpawan,Samuel 79 December 28, 2011 1pm Dextrose 5
in Water
Left Metacarpal
Vein
Introcan G22 500LiterX
KVO
10 drops/minute Zenaida Riboroso RN,MAN
62560
043903 Banawan,Francis 54 December 28, 2011 5pm 0.9 Sodium
Chloride
Solution
Left Metacarpal
Vein
Introcan G22 1LiterX
KVO
10 drops/minute Zenaida Riboroso RN,MAN
62560

II. Administering Intravenous Drugs
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
327324 Tachado,Editha 68 December 28, 2011 8am Sulbactam-
Ampicillin
Left Metacarpal
Vein
Introcan G20 1.5gm/ml
every 8
hours
20 drops/minute
Zenaida Riboroso RN,MAN
62560
558412 Cirineo,Desiree 39 December 28, 2011 12pm Mannitol Right Metacarpal
Vein
Introcan G24 200ml every
4 hours
31 drops/minute Zenaida Riboroso RN,MAN
62560
593007 Hermenora,Petra 76 December 28, 2011 12pm Piperacillin+
Tazobactam
Right Metacarpal
Vein
Introcan G22 2.25gm/ml
every 6
hours
20 drops/minute Zenaida Riboroso RN,MAN
62560
III. Administering and Maintaining Blood and Blood Components
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
485857 Andres, Decela 27 December 28,2011 2pm Type ~O(+)
Fresh Frozen
Plasma
Left Metacarpal
Vein
Introcan G18 250ml 30 drops/minute Zenaida Riboroso RN,MAN
62560
Submitted by: DOMINGO,1ANICE S. Date Submitted: February 22, 2011 Received by: 1ovita E. Pajarillo RN, MAN Approved by: Elena Tampican RN,MAN