3+3+1 ACCOMPLISHED REQUIREMENTS OF 3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES Name of Registered Nurse JEROME V. VILLAVERDE PRC Number 0854074______________ Name of Hospital offering IV Training DIVINE GRACE MEDICAL CENTER Provider No. #249_________________ Date of IV Training Program Attended FEBRUARY 25, 26, and 27, 2015 Venue MULTI-PURPOSE HALL___ I. Initiating/ Maintaining Peripheral IV Infusions Patient Number Name of The Patient Age Date Time Kind Of Infusion Site Type of Cannula Dose Rate Signature over Printed Name of Certified Trainer/ Preceptor/ M.D., R.N License Number 1053- 54156 Marieta I. Arieta 55 y.o 03/19/20 15 10 AM D5 PNSS 1Lx8h Left MCV Inyte G=22 1L 31- 32gtts Christian S. Tu 09- 047873 1053- 54149 Cecilla D. Sebastina 77 y.o 03/19/20 15 10 AM D5 NM 1Lx16h Right MCV Inyte G=24 1L 15- 16gtts Christian S. Tu 09- 047873 1503- 1065 Patricia Punzalan 25 y.o 03/19/20 15 05 PM D5 LR 1Lx8h Right MCV Inyte G=22 1L 31- 32gtts Christian S. Tu 09- 047873 II. Administering Intravenous Drugs Patient Number Name of The Patient Age Date Time Kind Of Infusion Site Type of Cannula Dose Rate Signature over Printed Name of Certified Trainer/ Preceptor/ M.D., R.N License Number 1053- 1062 Estelita Zamora 51 y.o 03/19/20 15 8 AM Omeprazole Right MCV Inyte G=22 40 mg OD Christian S. Tu 09- 047873 1053- 1094 Ma. Masiel I. Pakingan 4 y.o 03/19/20 15 8 AM Ampicilli- Sulbactam Right MCV Inyte G=24 500m g BID Christian S. Tu 09- 047873 1053- 1072 Liberato Santiago 73 y.o 03/19/20 15 8 AM Lanzoprazole Right MCV Inyte G=22 30 mg OD Christian S. Tu 09- 047873 III. Administering and Maintaining Blood and Blood Components (2NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)

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3+3+1 ACCOMPLISHED REQUIREMENTS OF3 DAY BASIC INTRAVENOUS THERAPY TRAINING PROGRAM FOR NURSES

Name of Registered Nurse JEROME V. VILLAVERDE PRC Number0854074______________Name of Hospital offering IV TrainingDIVINE GRACE MEDICAL CENTERProvider No.#249_________________Date of IV Training Program AttendedFEBRUARY 25, 26, and 27, 2015VenueMULTI-PURPOSE HALL___

I. Initiating/ Maintaining Peripheral IV InfusionsPatient NumberName of The PatientAgeDateTimeKind Of InfusionSiteType of CannulaDoseRateSignature over Printed Name of CertifiedTrainer/ Preceptor/ M.D., R.NLicense Number

1053-54156Marieta I. Arieta55 y.o03/19/201510 AMD5 PNSS 1Lx8hLeft MCVInyte G=221L31-32gttsChristian S. Tu09-047873

1053-54149Cecilla D. Sebastina77 y.o03/19/201510 AMD5 NM 1Lx16hRight MCVInyte G=241L15-16gttsChristian S. Tu09-047873

1503-1065Patricia Punzalan25 y.o03/19/201505 PMD5 LR 1Lx8hRight MCVInyte G=221L31-32gttsChristian S. Tu09-047873

II. Administering Intravenous DrugsPatient NumberName of The PatientAgeDateTimeKind Of InfusionSiteType of CannulaDoseRateSignature over Printed Name of CertifiedTrainer/ Preceptor/ M.D., R.NLicense Number

1053-1062Estelita Zamora51 y.o03/19/20158 AMOmeprazoleRight MCVInyte G=2240 mgODChristian S. Tu09-047873

1053-1094Ma. Masiel I. Pakingan4 y.o03/19/20158 AMAmpicilli- SulbactamRight MCVInyte G=24500mgBIDChristian S. Tu09-047873

1053-1072Liberato Santiago73 y.o03/19/20158 AMLanzoprazoleRight MCVInyte G=2230 mgODChristian S. Tu09-047873

III. Administering and Maintaining Blood and Blood Components (2NURSES IN ONE BLOOD TRANSFUSION ADMINISTRATION)Patient NumberName of The PatientAgeDateTimeKind Of InfusionSiteType of CannulaDoseRateSignature over Printed Name of CertifiedTrainer/ Preceptor/ M.D., R.NLicense Number

1053-0959Rosario R. Soberano75 y.o03/19/201510 AMPRBC 1 uRight MCVInyte G=22250cc6hChristian S. Tu09-047873

Submitted By: JEROME V. VILLAVERDE Date Submitted: MARCH 20, 2015 Received By: CHRISTIAN S. TU Approved By: LYNNET JOY A. PURIFICACION Signature over Printed Name Director of Nursing Services (Signature over Printed Name)

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