Sample- Or Dr Case 2013
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![Page 1: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/1.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student : CECILLE INNA M. ANDAYA( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZ
Clinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477
Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 2: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/2.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )
Level : 2
Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 3: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/3.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 4: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/4.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 5: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/5.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 6: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/6.jpg)
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 7: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/7.jpg)
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: Lifetime
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 8: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/8.jpg)
Date document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 9: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/9.jpg)
Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 10: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/10.jpg)
PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 11: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/11.jpg)
Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 12: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/12.jpg)
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZ
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 13: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/13.jpg)
Clinical Coordinator Chief Nurse DeanPRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 14: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/14.jpg)
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 15: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/15.jpg)
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -
![Page 16: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/16.jpg)
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
![Page 17: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/17.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student : CATHERINE JOY R. BAUTISTA( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
01/03/12, 3:18pm N.C.R 175752 Emergency Low Cervical Cesarean Section Levie G. Roncal, RN Benjamin G. Kinney, MAN
01/04/12, 5:10pm L.A.R 175533 Total Mastectomy Right Maria Victoria T. Datu, RN Benjamin G. Kinney, MAN
01/11/12, 6:38pm J.M.C 176190 Emergency Exploratory Laparotomy; Appendectomy Levie G. Roncal, RN Benjamin G. Kinney, MAN
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 18: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/18.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 19: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/19.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 20: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/20.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 21: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/21.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 22: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/22.jpg)
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 23: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/23.jpg)
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: Lifetime
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 24: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/24.jpg)
Date document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 25: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/25.jpg)
Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 26: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/26.jpg)
PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 27: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/27.jpg)
Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 28: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/28.jpg)
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 29: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/29.jpg)
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 30: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/30.jpg)
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature
Noted by: Concurred by: Approved by:
O.R. Form 1-A MAJOR - O.R. SCRUB FORM
![Page 31: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/31.jpg)
MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
![Page 32: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/32.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student : CECILLE INNA M. ANDAYA( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
11/16/12, 8:24 pm BB R. 176768 Delivery Room Leonora Fernandez, RMSylvia Pangilinan, MAN
11/17/12, 9:24 pm BB M. 176778Delivery Room
Leonora Fernandez, RMSylvia Pangilinan, MAN
11/23/12, 8:21 pm BB S. 176791Delivery Room
Grace Tamayo, RMSylvia Pangilinan, MAN
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 33: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/33.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 34: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/34.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 35: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/35.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 36: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/36.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 37: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/37.jpg)
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 38: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/38.jpg)
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: Lifetime
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 39: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/39.jpg)
Date document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 40: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/40.jpg)
Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 41: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/41.jpg)
PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 42: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/42.jpg)
PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 43: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/43.jpg)
Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 44: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/44.jpg)
PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON CAMILO D. DOMINGUEZ
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 45: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/45.jpg)
Clinical Coordinator Chief Nurse DeanPRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM
![Page 46: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/46.jpg)
ROSITA D. VIANZON CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing
![Page 47: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/47.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student : CECILLE INNA M. ANDAYA( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
11/16/12 3:55 pm A.M. 176773 Normal Spontaneous DeliveryLeonora Fernandez, RM Sylvia Pangilinan, MAN
13/01/12 9:39: pm C.S. 176813 Normal Spontaneous Delivery Leonora Fernandez, RM Sylvia Pangilinan, MAN
12/15/12 04:43 pm M.R. 176771 Normal Spontaneous Delivery Cecille Barion, RM Sylvia Pangilinan, MAN
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
D. R. FormACTUAL DELIVERY
FORM
![Page 48: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/48.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
D. R. FormACTUAL DELIVERY
FORM
![Page 49: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/49.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
D. R. FormACTUAL DELIVERY
FORM
![Page 50: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/50.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
D. R. FormACTUAL DELIVERY
FORM
![Page 51: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/51.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
D. R. FormACTUAL DELIVERY
FORM
![Page 52: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/52.jpg)
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
D. R. FormACTUAL DELIVERY
FORM
![Page 53: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/53.jpg)
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
D. R. FormACTUAL DELIVERY
FORM
![Page 54: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/54.jpg)
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: Lifetime
D. R. FormACTUAL DELIVERY
FORM
![Page 55: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/55.jpg)
Date document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012
D. R. FormACTUAL DELIVERY
FORM
![Page 56: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/56.jpg)
PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012
D. R. FormACTUAL DELIVERY
FORM
![Page 57: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/57.jpg)
PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477
D. R. FormACTUAL DELIVERY
FORM
![Page 58: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/58.jpg)
Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
D. R. FormACTUAL DELIVERY
FORM
![Page 59: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/59.jpg)
PRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZ
D. R. FormACTUAL DELIVERY
FORM
![Page 60: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/60.jpg)
Clinical Coordinator Chief Nurse DeanPRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
D. R. FormACTUAL DELIVERY
FORM
![Page 61: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/61.jpg)
ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing
BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY
Don Manuel H. Banzon Avenue, Balanga City, Bataan
(047) 237-5477, [email protected]
Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009
ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )
Prepared by:
Name of Student :( Printed Name & Signature of Student )
Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor
Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature
Noted by: Concurred by: Approved by:
D. R. FormACTUAL DELIVERY
FORM
![Page 62: Sample- Or Dr Case 2013](https://reader035.fdocuments.net/reader035/viewer/2022081413/5462072bb1af9f0d678b4904/html5/thumbnails/62.jpg)
ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean
PRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:
Time: Time: Time:
Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing