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IV Training Certification Document

This document certifies that a registered nurse completed an IV training program. It lists the name of the hospital that offered the training, the address, and the requirements that were accomplished. It documents the nurse's name, PRC number, and expiry date. It provides a table to record 3 patients for initiating and maintaining peripheral IV infusions, 3 for administering IV drugs, and 3 for administering and maintaining blood and blood components. The nurse certifies that the above requirements were successfully performed as witnessed and countersigned. The certification card number, date issued, and date submitted are also included.

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cindtan
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318 views1 page

IV Training Certification Document

This document certifies that a registered nurse completed an IV training program. It lists the name of the hospital that offered the training, the address, and the requirements that were accomplished. It documents the nurse's name, PRC number, and expiry date. It provides a table to record 3 patients for initiating and maintaining peripheral IV infusions, 3 for administering IV drugs, and 3 for administering and maintaining blood and blood components. The nurse certifies that the above requirements were successfully performed as witnessed and countersigned. The certification card number, date issued, and date submitted are also included.

Uploaded by

cindtan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Venue: ____

Name of Hospital Offering I V Training Province/Region:


_____ ANSAP Chapter: __________________
Address
Accomplished Requirements of:
Name of Registered Nurse: PRC No. _ Expiry Date:
Date of I V Training Program Attended: I V Requirements: _3 + 3 + 2_
Registration No. of Institution Offering the IV Training Program: __________

Date / Time / Site of I V Insertion Signature of Witness


Kind of IV
Name of Patient Age Type of Cannula / Dose / Rate / M.D./I V Trained
Infusion given
Drug Incorporation present Preceptor
I. Initiating & Maintaining Peripheral I V Infusions
1.
2.
3.
Drug Incorporated/
II. Administering I V Drugs Date / Time / Diagnosis
Dose
1
2.
3.
III. Administering & Maintaining Blood & Blood Components
Blood Type / Date / Time / Site of I V Insertions
Volume / Components Type of Cannula / Rate
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

I V Therapy Certification Card No. _____________________________ Approved by: ______________________________________________


Director, Nursing Service
Issued by: ____________________ Date: ______________________
Date Submitted: ____________________________________________

Note: To be submitted in duplicate to the ANSAP office within six (6) Months after Training.

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