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Mindanao Sanitarium & Hospital College: D.R. Form Actual Delivery Form

This document is an Actual Delivery Form from the Mindanao Sanitarium & Hospital College School of Nursing. It summarizes three deliveries supervised and witnessed by the nursing student Cristina L. Jayson. For each delivery, it records the date, time, patient initials, case number, type of delivery, delivering nurse, clinical instructor who supervised, and signatures of the clinical coordinator and dean who approved the documented experience.

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Cristina L. Jayson
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90 views1 page

Mindanao Sanitarium & Hospital College: D.R. Form Actual Delivery Form

This document is an Actual Delivery Form from the Mindanao Sanitarium & Hospital College School of Nursing. It summarizes three deliveries supervised and witnessed by the nursing student Cristina L. Jayson. For each delivery, it records the date, time, patient initials, case number, type of delivery, delivering nurse, clinical instructor who supervised, and signatures of the clinical coordinator and dean who approved the documented experience.

Uploaded by

Cristina L. Jayson
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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Mindanao Sanitarium & Hospital College

School of Nursing
Barangay San Miguel, Iligan City 9200
Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshnet@yahoo.com
Accredited By: Association of Christian Schools, Colleges and Universities Accrediting Agency, Incorporated
Accreditation Level: Level II, April 29, 2011 April 2014
Accredited By: Adventist Accrediting Association
Accreditation Level: Level II, October 4, 2010-December 31, 2012

ACTUAL DELIVERY in: Adventist Medical Center, Barangay San Miguel, Iligan City
Gregorio T. Lluch Memorial Hospital, Palao, Iligan City
Hospital/Home/Lying-in, Municipality/City/Province

Prepared by:
Printed name and Signature of Student: CRISTINA L. JAYSON


Date Performed
and
Time Started

Patients INITIAL Only

Case Number
(not applicable for Birthing/Lying-in
Clinics/Homes)

Type of Delivery

D. R. Nurse on Duty
(Name and Signature)
(If Midwife on Duty, Signature Not
Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

January 6, 2012
4:09 AM


ND
203287

Normal Spontaneous Vaginal
Delivery

Dyan Marie L. Villaver, RN
PRC Number: 0411677
Valid Until: November 1, 2015

Lucy May L. Bucayan, MN, RN
PRC Number: 0193232
Valid Until: May 25, 2016

October 12, 2012
7: 25 AM

EG
154393


Normal Spontaneous Vaginal
Delivery

Cheryl S. Epe, RN
PRC Number: 0318137
Valid Until: September 10, 2016

Daverly M. Caeda, MN, RN
PRC Number: 0364265
Valid Until: April 28, 2016

July 19, 2013
6:00 PM

JT
79256

Normal Spontaneous Vaginal
Delivery

Merlita B. Omlero, RM
PRC Number: 0101442
Valid Until: June 5, 2015

Daverly M. Caeda, MN, RN
PRC Number: 0364265
Valid Until: April 28, 2016

Noted by: EVALYN M. LECCIONES, MN, RN Approved by: GTER G, GAID, PhD, MAN, RN N
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0245303 Valid Until:May 9, 2015 Dean, PRC I.D. No.:0302269 Valid Until: September 13, 2015
Date document is signed: ________ Time:______________ Date document is signed: Time: ____________________
Please specify Highest Nursing Degree Earned: Master in Nursing Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
D.R. Form
ACTUAL DELIVERY FORM

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