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Transcript of prc form r.n.
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
Operating Room Form(Major and Minor)
Delivery Room Form(Delivery. Assist, and Cord Care)
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED
O.R. Nurse on Duty(Name AND Signature)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
November 26,2009 – 6:47PMF.A.65139-09
Primary Low Segment Transverse Caesarian Section Mrs. Rowena M. Escasinas Ms. Melinda Rabutin
July 26,2010 – 9:30 AMR.C.L.166907
Lobectomy Right, Isthmusectomy Mrs. Rowena M. Escasinas Dr. Betty Lynn C. Garingo
July 27,2010 – 10:50 AMD.G.B.161740
Cystoscopy, CystolithotripsyMs. Florence N. Juntilla Dr. Betty Lynn C. Garingo
July 27,2010 – 1:30 PMF.D.M.C.160179
Herniorrhapy Mesh RepairMrs. Lilibeth L. Punay Dr. Betty Lynn C. Garingo
July 30,2010 – 8:55 AMG.B.D.169131
AppendectomyMrs. Rowena M. Escasinas Dr. Betty Lynn C. Garingo
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)Republic of the Philippines
ODC Form 2AO.R. SCRUB FORM major
ODC Form 2BO.R. CIRCULATING FORM
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
SURGICAL SCRUB in VICENTE GULLAS MEDICAL CENTER/BANILAD/MANDAUE CITY Hospital/ Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED
O.R. Nurse on Duty(Name AND Signature)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
November 27,2009 – 4:00 PMD.T.M.01-0334
DebridementMs. Lenie M. Sombilon Mr. Phillip Mark Bueno
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
Republic of the Philippines
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
SURGICAL SCRUB in LAPU-LAPU DISTRICT HOSPITAL/LAPU-LAPU CITY Hospital/ Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED
O.R. Nurse on Duty(Name AND Signature)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
January 26,2010 – 7:30 PMR.P.B.2010-266
SuturingMrs. Gina Gollez Menguito Mr. Wilson B. Maxilom
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 2BO.R. CIRCULATING FORM
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
SURGICAL SCRUB in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED
O.R. Nurse on Duty(Name AND Signature)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
October 13,2010J.S.A.10-10017
EpisiorraphyMs. Teresita Y. Sayson Mrs. Annabelle A. Catalan
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
Republic of the Philippines
ODC Form 2BO.R. CIRCULATING FORM
ODC Form 2BO.R. CIRCULATING FORM
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only SURGICAL PROCEDUREPERFORMED
O.R. Nurse on Duty(Name AND Signature)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
August 25,2009 – 9:05 AMS.N.P.65937 - 2009
Excision BiopsyMrs. Preciosa V. Borinaga Mrs. Josephine A. Alo
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
Republic of the PhilippinesProfessional Regulation Commission
ODC Form 1AActual Delivery Form
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
ACTUAL DELIVERY in GRENGIA MATERNITY HOUSE/LAPU-LAPU Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
December 09,2009 – 1:51 PMA.A.1599-2009
Normal Spontaneous Vaginal Delivery Dr. Josephus Grengia Mrs. Loida B. Alondres
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
Republic of the Philippines
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
ACTUAL DELIVERY in EVERSLY CHILD SANITARIUM/JAGOBIA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
January 29,2010 – 10:15 AMS.G.085249
Normal Spontaneous Vaginal Delivery Ms. Jasmin A. Pepito Mrs. Loida B. Alondres
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1AActual Delivery Form
Republic of the Philippines
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
ACTUAL DELIVERY in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
October 14, 2010 – 1:43 PMS.O.T.10-10090
Normal Spontaneous Vaginal Delivery Mrs. Teresita Y. Sayson Mrs. Annabelle A. Catalan
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1AActual Delivery Form
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
ACTUAL DELIVERY in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only PROCEDURE PERFORMED
ASSISTED DELIVERY
D.R. Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
July 10,2009 – 1:20 AMA.D.55622-2009
Normal Spontaneous Vaginal Delivery
Mrs. Nelpha B. Obordo Mrs. Ma. Flor L. Operario
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1BASSISTED Delivery Form
Republic of the Philippines
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
ACTUAL DELIVERY in EVERSLY CHILD SANITARIUM/JAGOBIA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only PROCEDURE PERFORMED
ASSISTED DELIVERY
D.R. Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
January 25,2010 – 9:50 AMA.T.024950
Normal Spontaneous Vaginal Delivery Ms. Jasmin A. Pepito Mrs. Loida B. Alondres
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1BASSISTED Delivery Form
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
ACTUAL DELIVERY in MANDAUE CITY HOSPITAL/MANDAUE CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only PROCEDURE PERFORMED
ASSISTED DELIVERY
D.R. Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
May 12,2010 – 9:44 PMZ.T.N.13832-A
Normal Spontaneous Vaginal Delivery Mrs. Ma. Georgia Lada Mr. Sergio Valiente
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1BASSISTED Delivery Form
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
IMMEDIATE NEWBORN CORD CARE in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
May 19,2010 – 12:40 AMJ.D.O.148083
Neonate Intensive Care UnitMrs. Ediza P. Sabang Mrs. Armida B. Gutierrez
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1CCORD CARE FORM
Republic of the Philippines
Professional Regulation CommissionBoard of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
IMMEDIATE NEWBORN CORD CARE in LAPU-LAPU DISTRICT HOSPITAL/LAPU-LAPU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
July 12,2010 – 8:30 PMA.D.M.40682
Delivery RoomMrs. Ma. Lilane D. Berdin Mrs. Edna E. Reroma
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1CCORD CARE FORM
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
IMMEDIATE NEWBORN CORD CARE in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
October 12,2010 – 11:57 AMC.N.A.1010200
Delivery RoomMrs. Teresita Y. Sayson Mrs. Annabelle A. Catalan
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1CCORD CARE FORM
Republic of the PhilippinesProfessional Regulation Commission
Board of Nursing
UNIVERSITY OF THE VISAYASCollege of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
IMMEDIATE NEWBORN CORD CARE in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
Date Performed andTime Started
Patient’s INITIAL only Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
Nurse on Duty(Name AND Signature)
(If Midwife on duty, Signature not required)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
October 12,2010 – 4:27 PMJ.M.O.10-10014
Delivery RoomMrs. Mary M. Aberia Mrs. Annabelle A. Catalan
Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
(STRICTLY NO DESIGNATES)
ODC Form 1CCORD CARE FORM