IV Infusion Therapy Treatment Record
Complete this patient chart based on the IV infusion therapy session. Preserve the original labels and grouping as closely as possible.
Patient & Visit Information
Patient Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Date of Service
*
-
Month
-
Day
Year
Date
Session #
*
IV Drip Details
IV Drip Received Today
*
The Clarity Drip
The Radiance Drip
The Revival Drip
The Balance Drip
Myers Cocktail
Custom
Infusion Start Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Infusion End Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
IV Site Location
*
Catheter Gauge Used
*
Product Lot Number(s) Administered
*
Vital Signs
Blood Pressure
*
Heart Rate
*
Temperature
*
Oxygen Saturation
*
Clinical Screening / Safety Checks
Patient reports no new medical conditions or medications since last visit or intake form
*
Yes
No
Patient reports no new allergies or sensitivities
*
Yes
No
Consent form on file (or signed today for first-time patients)
*
Yes
No
Standing order confirmed active with Medical Director prior to infusion
*
Yes
No
Patient tolerated infusion without complaint
*
Yes
No
Any adverse events or reactions during session
*
Yes
No
Adverse Events & RN Notes
If yes, describe adverse event and actions taken
Additional RN observations
Patient Acknowledgment
Patient acknowledgment
*
I received the IV infusion drip indicated above today.
I have reported any adverse symptoms, discomfort, or reactions experienced during or after the infusion.
I understand I should contact the clinic immediately if I experience any unusual symptoms after leaving.
Acknowledgment of infusion completion
*
I received the IV infusion drip indicated above today.
Acknowledgment of post-infusion guidance
*
I understand I should contact the clinic immediately if I experience any unusual symptoms after leaving.
Signatures & Provider Info
Patient Signature
*
Patient Signature Date
*
-
Month
-
Day
Year
Date
RN Name (Print) & License Number
*
RN Signature
*
Submit
Submit
Should be Empty: