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3+3+1 ACCOMPLISHED REQUIREMENTS of 3-DAY BASIC THERAPY TRAINING PROGRAM for NURSES Name of the registered Nurse: Name

of Hospital offering IV Training: Date of IV Training Program Attended: JOHN MARK F. GAN MMMH & MC October 19-21 PRC Number: On the Process Provider No. 192 Venue: Training Center MMMH & MC

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/ M.D., RN Nixon F. Zafaralia, RN Nixon F. Zafaralia, RN Rosalinda A. Oducayen, RN License Number

638027 638027 642405

Gliceria Tabay Gliceria Tabay Catalina S. Gappi

62 62 55

10-27-12 10-27-12 10-29-12

8:20 AM 8:20 AM 3:30 PM

PNSS PLRS PNSS

Right Basilic Right Basilic Right cephalic

luer Lock Gauge 18 1L luer Lock Gauge 18 250ml Luer Lock Gauge 20 1L 41 ugtts 14 ugtts 0690031 0122079 33 ugtts 0690031

II.

Administering of Intravenous Drugs


Patient No. 638027 638027 638027 Name of the Patient Age Date Time Drugs Incorporated Cefuroxime Paracetamol Omeprazole Dose Diagnosis Signature over printed name of certified trainer/ preceptor/ M.D., RN Nixon F. Zafaralia, RN Nixon F. Zafaralia, RN Nixon F. Zafaralia, RN License Number 0690031 0690031 0690031

Gliceria Tabay Gliceria Tabay Gliceria Tabay

62 62 62

10-27-12 10-27-12 10-27-12

10:00 AM 2:00 PM 3:00 PM

750mg 300 mg 40mg

Serous carcinoma, moderately differentiated, endometrium s/p manual evacuationof uterine content biopsy

III.

Admninistraion and Maintaining of Blood and Blood Components ( 2 Nurses in One Blood Transfusion Administration) Patient Name of the patient Age Date Time Volume/ IV Type of Cannula No. Blood Type/ insertion Components/ Rate 450cc/ B+/ PRBC/

Diagnosis

Signature over printed name of certified trainer/ preceptor/ M.D., RN

License No.

641745

Ismaelda Erice

52

10-29-12

7:30 PM

Left cephalic

Luer lock Gauge 18

T/C UTI; DM Neuropathy ; CKDIII secondary to DM Nephropathy anemia DM 2, HPN stage II

0122079 Rosalinda A. Oducayen, RN

Submitted By: JOHN MARK F. GAN, RN

Date Submitted: October 31, 2012

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