University Of St.
La Salle College of Nursing
La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
SURGICAL SCRUB in ______________________________________________________________________ Hospital, Municipality/City/Province
Prepared by:
O.R. Form 1A O.R. SCRUB FORM Major
(Printed Name and Signature of Student)
Date Performed and Time Started 05-19-11 6:22 AM
Patient's INITIALS (ONLY) Case Number SURGICAL PROCEDURE PERFORMED OR Nurse On Duty (Name and Signature)
Supervised By (Clinical Instructor) Name and Signature Myrvi P. Vergara, RN, MN
M.L.
02031608
Appendectomy Cystoscopy with retrograde pyelography; Transurethral resection of bladder tumor Debridement; Open reduction; Internal fixation; Intramedullary pinning, ulna, left
05-19-11
8:44 AM
R.E.
02020456
Myrvi P. Vergara, RN, MN
10-28-11
12:28 PM
R.M.
02072347
Hermie G. Siroy, RN, MN
Noted by:
Mary Beth P. Diva, RN, MN
Clinical Coordinator
Approved by:
Josephine L. de la Serna, RN, MN
Dean
PRC ID No.: Date document is signed:
0214975
Valid Until: Time:
07-23-12
PRC ID No.:
0037515
Valid Until: Time:
06-03-14
Master in Nursing
Date document is signed: Highest Nursing Degree Earned:
Highest Nursing Degree Earned:
Master in Nursing
University Of St. La Salle College of Nursing
La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
SURGICAL SCRUB in __________________________________________________________________________ Hospital, Municipality/City/Province
Prepared by:
O.R. Form 1B O.R. CIRCULATING FORM
(Printed Name and Signature of Student)
Date Performed and Time Started
Patient's INITIALS (ONLY) SURGICAL PROCEDURE PERFORMED Case Number Cholecystectomy; Common Bile Duct Exploration; T-tube; Intaoperative Cholangiogram; Excision of choledochal cyst; Hepaticojejunostomy; Jejunostomy; Roux-eny; Jackson Pratt Drain
Cesarean section, primary, low transverse cut
OR Nurse On Duty (Name and Signature)
Supervised By (Clinical Instructor) Name and Signature
05-19-11
12:06 PM
A.G.
02028514
Myrvi P. Vergara, RN, MN
08-04-11
11:00 AM
C.C.L.
02050484
Myrvi P. Vergara, RN, MN
10-28-11
8:52 AM
J.C.
02069383
Open reduction; Internal fixation; Intramedullary nailing, tibia, right
Hermie G. Siroy, RN, MN
Noted by: PRC ID No.: Date document is signed: Highest Nursing Degree Earned:
Mary Beth P. Diva, RN, MN
Clinical Coordinator
Approved by:
Josephine L. de la Serna, RN, MN
Dean
0214975
Valid Until: Time:
07-23-12
PRC ID No.:
0037515
Valid Until: Time:
06-03-14
Master in Nursing
Date document is signed: Highest Nursing Degree Earned:
Master in Nursing
University Of St. La Salle College of Nursing
La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
ACTUAL DELIVERY in __________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
D. R. Form ACTUAL DELIVERY FORM
(Printed Name and Signature of Student)
Bliss Vinco Caraig
Date Performed and Time Started 08-06-11 3:41 PM
Patient's INITIAL (only) PROCEDURE PERFORMED Case Number
DR Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
Supervised By (Clinical Instructor) Name and Signature Myrvi P. Vergara, RN, MN
S.M.T.
11-3205
Normal Spontaneous Vaginal Delivery
09-09-11
4:45 PM
G.A.
11-5054
Normal Spontaneous Vaginal Delivery
Arnella V. Bancaya, RN, MN
Noted by: PRC ID No.: Date document is signed: Highest Nursing Degree Earned:
Mary Beth P. Diva, RN, MN
Clinical Coordinator
Approved by:
Josephine L. de la Serna, RN, MN
Dean
0214975
Valid Until: Time:
07-23-12
PRC ID No.:
0037515
Valid Until: Time:
06-03-14
Date document is signed: Highest Nursing Degree Earned:
Master in Nursing
Master in Nursing
University Of St. La Salle College of Nursing
La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
ACTUAL DELIVERY in Pontevedra Rural Health Unit, Pontevedra, Negros Occidental Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
D. R. Form ACTUAL DELIVERY FORM
(Printed Name and Signature of Student)
BLISS V. CARAIG
Date Performed and Time Started 05-25-11 7:27 AM
Patient's INITIAL (only) PROCEDURE PERFORMED Case Number
DR Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) Ana Jurada, RM
Supervised By (Clinical Instructor) Name and Signature
Gardenia T. de los Santos, RN, MN
E.M.
2011-323
Normal Spontaneous Vaginal Delivery
Noted by: PRC ID No.: Date document is signed: Highest Nursing Degree Earned:
Mary Beth P. Diva, RN, MN
Clinical Coordinator
Approved by:
Josephine L. de la Serna, RN, MN
Dean
0214975
Valid Until: Time:
07-23-12
PRC ID No.:
0037515
Valid Until: Time:
06-03-14
Date document is signed: Highest Nursing Degree Earned:
Master in Nursing
Master in Nursing
University Of St. La Salle College of Nursing
La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
IMMEDIATE NEWBORN CORD CARE in Teresita Lopez Jalandoni Provincial Hospital, Silay City, Negros Occidental Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
ICNB Form IMMEDIATE CARE OF THE NEWBORN FORM
(Printed Name and Signature of Student)
BLISS V. CARAIG
Date Performed and Time Started 08-03-11 8:29 AM
Patient's INITIAL (only) Case Number
Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
DR/Nursery Nurse On Duty
(Name and Signature) (If Midwife on Duty, Signature Not Required)
Supervised By (Clinical Instructor) Name and Signature Arnella V. Bancaya RN, MN
G.L.
11-3144
Delivery Room
Cecilia Tabat, RM
08-03-11
3:22 PM
G.A.
11-3157
Delivery Room
Neila Rose Parreas, RM
Arnella V. Bancaya RN, MN
09-09-11
11:57 AM
B.R.
11-5047
Delivery Room
Cecilia Tabat, RM
Kristel Marie D. Artagame RN, MN
Noted by:
Mary Beth P. Diva, RN, MN
Clinical Coordinator
Approved by:
Josephine L. de la Serna, RN, MN
Dean
PRC ID No.: Date document is signed:
0214975
Valid Until: Time:
07-23-12
PRC ID No.:
0037515
Valid Until: Time:
06-03-14
Date document is signed: Highest Nursing Degree Earned:
Highest Nursing Degree Earned:
Master in Nursing
Master in Nursing
