University Of San Carlos 694v1f
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UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
ODC Form 1A ACTUAL DELIVERY FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ACTUAL DELIVERY in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started November 23, 2010 7:14 AM
Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names)
PROCEDURE PERFORMED
J.S.B 01-42-59
Actual Delivery
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN
D.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Nanine G. Gomez, RN
Khristle Ann C. Cañares, RN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN
(Print Name and Signature)
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 2012 Date document is signed ________________________
Time _____ ________
Dean, PRC I.D. No. 0054229 Valid Until August 05, Date document is signed________________ Time _______________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Nursing_________
Specify Highest Nursing Degree Earned Master in
Master of Arts in Nursing____
Master of
Science in Nursing
(STRICTLY NO DESIGNATES) UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ACTUAL DELIVERY in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
ODC Form 1B ASSISTED DELIVERY FORM
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started November 23, 2010 4:40 AM
Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names)
PROCEDURE PERFORMED
J.R.V 02-53-92
.Assisted Delivery
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN
O.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Maria February Lin Y. Matigas, RN
Khristle Ann C. Cañares, RN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN
(Print Name and Signature)
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No 0190308 Date document is signed ____________
Valid Until June 22, 2011
_____
Time _____ _________
Dean, PRC I.D. No.
0054229 Valid Until August 05, 2012
Date document is signed____________________ Time ___________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Specify Highest Nursing Degree Earned Master in Nursing__________ Master of Arts in Nursing Master of Science in Nursing
(STRICTLY NO DESIGNATES) UNIVERSITY OF SAN CARLOS
ODC Form 1C
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
CORD CARE FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
IMMEDIATE NEWBORN CORD CARE in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started November 21, 2010 1:25 AM
Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names) B.G.V 02-53-82
IMMEDIATE NEWBORN CORD CARE PERFORMED (Indicate where performed e.g. D.R.,Nursery,NICU, or Home) Delivery Room
O.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required) Nanine G. Gomez, RN
SUPERVISED BY Clinical Instructor (Name and Signature) Khristle Ann C. Cañares, RN, MAN
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN_
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN _
(Print Name and Signature) Clinical Coordinator, PRC I.D. No 0190308 2012
(Print Name and Signature) Valid Until June 22, 2011
Date document is signed ______________________ _____________
Time ________________
Dean, PRC I.D. No. 0054229
Valid Until August 05,
Date document is signed ___________________ Time
Please specify Highest Nursing Degree Earned Master of Science in Nursing__ Specify Highest Nursing Degree Earned Master in Nursing____________ Master of Arts in Nursing Master of Science in Nursing__
(STRICTLY NO DESIGNATES)
UNIVERSITY OF SAN CARLOS
ODC Form 2A
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
O.R. SCRUB FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph
MAJOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
SURGICAL SCRUB in
Vicente Sotto Memorial Medical Center_
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student:
Date Performed and Time Started April 28, 2010 2:05 pm
Gracel R. Flores _
Patient’s INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
Exploratory Laparatomy
Emmylou D. Hermosa, RN
Case Number C.C.A 107301
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN (Print Name and Signature) Clinical Coordinator, PRC I.D. No 0190308
SUPERVISED BY Clinical Instructor (Name and Signature) Khristle Ann C. Cañares, RN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN (Print Name and Signature)
Valid Until June 22, 2011
Date document is signed ____________________
Time _______________
Dean, PRC I.D. No.
0054229 Valid Until August 05, 2012
Date document is signed____________________ Time _________________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Nursing_______________ Master of Science in Nursing______
Specify Highest Nursing Degree Earned Master in Master of Arts in Nursing_ _
(STRICTLY NO DESIGNATES)
UNIVERSITY OF SAN CARLOS
ODC Form 2B
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
O.R. SCRUB FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph
MINOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
SURGICAL SCRUB in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started
November 22, 2010 8:20 AM
Patient’s INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY Clinical Instructor (Name and Signature)
Episiorraphy
Amalia C. Margallo, RN
Khristle Ann C. Cañares, RN, MAN
Case Number
J.M.V 02-45-92
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN, MSN
(Print Name and Signature) Clinical Coordinator, PRC I.D. No 0190308
(Print Name and Signature) Valid Until June 22, 2011
Date document is signed ___________________ Time _________________
Dean, PRC I.D. No. 0054229
Valid Until August 05,2012
Date document is signed__________________ Time ______________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Nursing___________ Master of Science in Nursing__
Specify Highest Nursing Degree Master of Arts in Nursing____
(STRICTLY NO DESIGNATES)
Earned
Master
in
ODC Form 1A ACTUAL DELIVERY FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ACTUAL DELIVERY in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started November 23, 2010 7:14 AM
Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names)
PROCEDURE PERFORMED
J.S.B 01-42-59
Actual Delivery
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN
D.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Nanine G. Gomez, RN
Khristle Ann C. Cañares, RN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN
(Print Name and Signature)
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 2012 Date document is signed ________________________
Time _____ ________
Dean, PRC I.D. No. 0054229 Valid Until August 05, Date document is signed________________ Time _______________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Nursing_________
Specify Highest Nursing Degree Earned Master in
Master of Arts in Nursing____
Master of
Science in Nursing
(STRICTLY NO DESIGNATES) UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ACTUAL DELIVERY in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
ODC Form 1B ASSISTED DELIVERY FORM
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started November 23, 2010 4:40 AM
Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names)
PROCEDURE PERFORMED
J.R.V 02-53-92
.Assisted Delivery
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN
O.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Maria February Lin Y. Matigas, RN
Khristle Ann C. Cañares, RN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN
(Print Name and Signature)
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No 0190308 Date document is signed ____________
Valid Until June 22, 2011
_____
Time _____ _________
Dean, PRC I.D. No.
0054229 Valid Until August 05, 2012
Date document is signed____________________ Time ___________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Specify Highest Nursing Degree Earned Master in Nursing__________ Master of Arts in Nursing Master of Science in Nursing
(STRICTLY NO DESIGNATES) UNIVERSITY OF SAN CARLOS
ODC Form 1C
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
CORD CARE FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
IMMEDIATE NEWBORN CORD CARE in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started November 21, 2010 1:25 AM
Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names) B.G.V 02-53-82
IMMEDIATE NEWBORN CORD CARE PERFORMED (Indicate where performed e.g. D.R.,Nursery,NICU, or Home) Delivery Room
O.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required) Nanine G. Gomez, RN
SUPERVISED BY Clinical Instructor (Name and Signature) Khristle Ann C. Cañares, RN, MAN
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN_
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN _
(Print Name and Signature) Clinical Coordinator, PRC I.D. No 0190308 2012
(Print Name and Signature) Valid Until June 22, 2011
Date document is signed ______________________ _____________
Time ________________
Dean, PRC I.D. No. 0054229
Valid Until August 05,
Date document is signed ___________________ Time
Please specify Highest Nursing Degree Earned Master of Science in Nursing__ Specify Highest Nursing Degree Earned Master in Nursing____________ Master of Arts in Nursing Master of Science in Nursing__
(STRICTLY NO DESIGNATES)
UNIVERSITY OF SAN CARLOS
ODC Form 2A
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
O.R. SCRUB FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph
MAJOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
SURGICAL SCRUB in
Vicente Sotto Memorial Medical Center_
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student:
Date Performed and Time Started April 28, 2010 2:05 pm
Gracel R. Flores _
Patient’s INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
Exploratory Laparatomy
Emmylou D. Hermosa, RN
Case Number C.C.A 107301
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN (Print Name and Signature) Clinical Coordinator, PRC I.D. No 0190308
SUPERVISED BY Clinical Instructor (Name and Signature) Khristle Ann C. Cañares, RN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN,MSN (Print Name and Signature)
Valid Until June 22, 2011
Date document is signed ____________________
Time _______________
Dean, PRC I.D. No.
0054229 Valid Until August 05, 2012
Date document is signed____________________ Time _________________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Nursing_______________ Master of Science in Nursing______
Specify Highest Nursing Degree Earned Master in Master of Arts in Nursing_ _
(STRICTLY NO DESIGNATES)
UNIVERSITY OF SAN CARLOS
ODC Form 2B
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
O.R. SCRUB FORM
PHONE: 032 3433005; FAX 032 3433006; [email protected]; www.usc.edu.ph
MINOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
SURGICAL SCRUB in Juan B. Dosado Memorial Hospital, Sugod, Cebu Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name with Signature of Student: JEZIEL JOY C. CORITICO
Date Performed and Time Started
November 22, 2010 8:20 AM
Patient’s INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY Clinical Instructor (Name and Signature)
Episiorraphy
Amalia C. Margallo, RN
Khristle Ann C. Cañares, RN, MAN
Case Number
J.M.V 02-45-92
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN
Approved by: ANTONIA F. PASCUAL, RN, MN, MSN
(Print Name and Signature) Clinical Coordinator, PRC I.D. No 0190308
(Print Name and Signature) Valid Until June 22, 2011
Date document is signed ___________________ Time _________________
Dean, PRC I.D. No. 0054229
Valid Until August 05,2012
Date document is signed__________________ Time ______________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Nursing___________ Master of Science in Nursing__
Specify Highest Nursing Degree Master of Arts in Nursing____
(STRICTLY NO DESIGNATES)
Earned
Master
in
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