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IV Insertion

This document is a form from the Professional Regulation Commission for midwives to record their actual intravenous insertions as required for their certification. It requests information about the midwife applicant, the patient, the diagnosis, date and time of the procedure, the facility where it took place, the supervising medical professional, and their signature and license information. It notes the requirements that graduate midwives must be supervised by qualified faculty or clinical instructors, and that supervising registered midwives and clinical instructors must have training in intravenous insertions.

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Nars Dan Doms
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247 views1 page

IV Insertion

This document is a form from the Professional Regulation Commission for midwives to record their actual intravenous insertions as required for their certification. It requests information about the midwife applicant, the patient, the diagnosis, date and time of the procedure, the facility where it took place, the supervising medical professional, and their signature and license information. It notes the requirements that graduate midwives must be supervised by qualified faculty or clinical instructors, and that supervising registered midwives and clinical instructors must have training in intravenous insertions.

Uploaded by

Nars Dan Doms
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PRC FORM NO.

107 PROFESSIONAL REGULATION COMMISION


(Revised October 2010) Manila
Board of Midwifery
Record of Actual Intravenous Insertions
Please Check:
Graduate Midwife Registered Nurse

Name of Applicant: ________________________________ School: UNIVERSITY OF CAGAYAN VALLEY
Name and Address of patient
Case
No.
Complete
Diagnosis
(Gravida_ Para_)
Date &
Time
Perform
Full Name, Address
of Facility & Contact
Number
Check
if Home
Del.
Supervised By:
Printed Name &
Contact No.
Position/
Designation
Signature
License
No. /Exp.
Date
1.
2.
3
4


5


NOTE: 1) For graduate midwives: Supervision must be by qualified faculty/ Clinical instructor.
2) Registered Midwives/ Clinical Instructors who supervise the student midwives and affix their signature in this Form must present a Certificate of
Training on Intravenous Insertions to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.

Subscribed and sworn to me before this________________ at __________________ Affiant exhibiting
to me his/her Residence Certificate No. _______________ issued at _____________on_____________.
CERTIFIED CORRECT:
Signature: ______________________ Date:__________________
________________________________ Printed Name: _______________________________
Administering Officer or Notary Public Designation: _________________________________
Lic. No.: __________________ Expiry Date: _________________
Affix
Documentary Stamp
(to be posted on the last page)

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