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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: ___________________________ Received By: ______________________ Approved By: _______________________________ Signature over Printed Name Director of Nursing Services (Signature over Printed Name)