PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya Tel. No. (078) 805-3682. Fax No. (078) 321-2397 ACTUAL DELIVERY in VETERANS REGIONAL HOSPITAL NUEVA VIZCAYA PROVINCIAL HOSPITAL

ODC Form 1 A ACTUAL DELIVERY FORM

Prepared by: IRISH JOY P. ANDELEON Name and Signature Patients INITIAL Only Case Number (not applicable for Birthing/ Lying-In Clinics/Homes)

Date Performed And Time Started

PROCEDURE PERFORMED

D.R NURSE ON DUTY (Name and Signature) (If Midwife on Duty, Signature not Required)
Perlita P. Bragado, RN, MAN PRC #: 0062407 Validity: April 18, 2015 Date Signed:__________

SUPERVISED BY Clinical Instructor Name and Signature

Leani G. Bongayon, RN, MAN PRC #: 0317435 Validity: April 18, 2015 Date Signed:__________ Julie Ann T. Garnace, RN PRC #: 0344244 Validity: July 27, 2015 Date Signed:__________ Fidelito H. Salinas, RN, MAN PRC #: 0552433 Validity: February 2, 2015 Date Signed:__________

January 6, 2011 8:10 AM

E.M Case # 006

Normal Spontaneous Delivery with support to alive Bb. Boy

January 15, 2011 5:30 PM

A.B Case # 151

Normal Spontaneous Delivery with support to alive Bb. Boy

Rowena C. Agacid, RN

March 3, 2012 11:30 AM

M.V Case # 3064

Normal Spontaneous Delivery Right Mediolateral Episiotomy

Franco Reinaldo R. Ganacias, RN PRC #: 0359302 Valid until: August 19, 2013 Date Signed:__________

Noted by:

CONSTANCIA A. SOUISSI, RN, MSN Printed Name and Signature Clinical Coordinator, PRC I.D. No. 0104473 Valid Until: September 19, 2015 Date document is signed: _____________________ Time ______________ Masteral Degree: Master of Science in Nursing

JOSSA ROWENA F. RAMOS RN, MSN Printed Name and Signature Dean, PRC I.D. No. 0253737 Valid Until: December 9, 2013 Date document is signed: _____________________ Time ____________ Masteral Degree: Master of Science in Nursing

Approved by:

PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya Tel. No. (078) 805-3682. Fax No. (078) 321-2397
CORD CARE in VETERANS REGIONAL HOSPITAL ODC FORM 1C CORD CARE FORM

Prepared by: IRISH JOY P. ANDELEON Name and Signature

Date Performed And Time Started

Patients INITIAL Only Case Number (not applicable for Birthing/ Lying-In Clinics/Homes)

IMMEDIATE NEWBORN CORD CARE PERFOMED Indicate where performed e.g. D.R., Nursery NICU, or Home Bb. Boy VRH Delivery Room

D.R NURSE ON DUTY (Name and Signature) (If Midwife on Duty, Signature not Required)
Ma. Luisa D. Gomez, RN PRC #: 0253025 Validity: July 7, 2015 Date Signed:__________ Perlita P. Bragado, RN, MAN PRC #: 0062407 Validity: April 18, 2015 Date Signed:__________ Imelda M. Bangloy, RN, MAN PRC #: 0269672 Validity: September 26, 2015 Date Signed:__________

SUPERVISEDBY Clinical Instructor Name and Signature

March 15, 2012 8:06 PM

J.A Case # 139

Julie Ann T. Garnace, RN PRC #: 0344244 Validity: July 27, 2015 Date Signed:__________ Julie Ann T. Garnace, RN PRC #: 0344244 Validity: July 27, 2015 Date Signed:__________ Julie Ann T. Garnace, RN PRC #: 0344244 Validity: July 27, 2015 Date Signed:__________

March 17, 2012 9:11 PM

J. DC Case # 160

Bb. Boy VRH Delivery Room

March 24, 2012 5:35 PM

L. N Case # 205

Bb. Boy VRH Delivery Room

Noted by:

CONSTANCIA A. SOUISSI, RN, MSN Printed Name and Signature Clinical Coordinator, PRC I.D. No. 0104473 Valid Until: September 19, 2015 Date document is signed: _____________________ Time ______________ Masteral Degree: Master of Science in Nursing

JOSSA ROWENA F. RAMOS RN, MSN Printed Name and Signature Dean, PRC I.D. No. 0253737 Valid Until: December 9, 2013 Date document is signed: _____________________ Time ____________ Masteral Degree: Master of Science in Nursing

Approved by:

PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya Tel. No. (078) 805-3682. Fax No. (078) 321-2397 ASSISTED DELIVERY in VETERANS REGIONAL HOSPITAL NUEVA VIZCAYA PROVINCIAL HOSPITAL Prepared by: IRISH JOY P. ANDELEON Name and Signature

ODC Form 1 B ASSISTED DELIVERY FORM

Date Performed And Time Started

Patients INITIAL Only Case Number (not applicable for Birthing/ Lying-In Clinics/Homes) S. M Case # 066

PROCEDURE PERFORMED ASSISTED DELIVERY

D.R NURSE ON DUTY (Name and Signature) (If Midwife on Duty, Signature not Required) Rosenia S. Marzan, RN, MAN

SUPERVISEDBY Clinical Instructor Name and Signature

Leani G. Bongayon, RN, MAN PRC #: 0317435 Validity: April 18, 2015 Date Signed:__________ Fidelito H. Salinas, RN, MAN PRC #: 0552433 Validity: February 2, 2015 Date Signed:__________ Julie Ann T. Garnace, RN PRC #: 0344244 Validity: July 27, 2015 Date Signed:__________

July 9, 2010 12:45 PM

Normal Spontaneous Delivery with Median Episiotomy Repair

March 1, 2012 9:19 AM

M. V Case # 2999

Normal Spontaneous Delivery (Forcep Delivery)

Rolina R. Niegas, RN PRC #: 0243424 Validity: February 4, 2014 Date Signed:__________ Filipina C. Sagun, RN, MAN PRC #: 0146488 Validity: November 30, 2013 Date Signed:__________

March 16, 2012 10:00 PM

L. A Case # 153

VBAC 2x with Right Mediolateral Episiotomy Repair

Noted by:

CONSTANCIA A. SOUISSI, RN, MSN Printed Name and Signature Clinical Coordinator, PRC I.D. No. 0104473 Valid Until: September 19, 2015 Date document is signed: _____________________ Time ______________ Masteral Degree: Master of Science in Nursing

JOSSA ROWENA F. RAMOS RN, MSN Printed Name and Signature Dean, PRC I.D. No. 0253737 Valid Until: December 9, 2013 Date document is signed: _____________________ Time ____________ Masteral Degree: Master of Science in Nursing

Approved by:

PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya Tel. No. (078) 805-3682. Fax No. (078) 321-2397 O. R. SCRUB in NUEVA VIZCAYA PROVINCIAL HOSPITAL Prepared by: IRISH JOY P. ANDELEON Name and Signature

ODC Form 2 A O.R SCRUB FORM Major

Date Performed And Time Started August 16, 2011 10:20 AM

Patients INITIAL Only _____________ Case Number H. A Case # 10687

SURGICAL PROCEDURE PERFORMED

O.R NURSE ON DUTY (Name and Signature)

SUPERVISEDBY Clinical Instructor Name and Signature

Fidelito H. Salinas, RN, MAN PRC #: 0552433 Validity: February 2, 2015 Date Signed:__________ Fidelito H. Salinas, RN, MAN PRC #: 0552433 Validity: February 2, 2015 Date Signed:__________

Low Sacral Cesarean Section 2x

Marlowe Lito A. Crisostomo, RN PRC #: 0347865 Validity: May 6, 2015 Date Signed:__________ Marlowe Lito A. Crisostomo, RN PRC #: 0347865 Validity: May 6, 2015 Date Signed:__________

March 10, 12 7:52 AM

C. DC Case # 3370

Subtotal Hysterectomy

Noted by:

CONSTANCIA A. SOUISSI, RN, MSN Printed Name and Signature Clinical Coordinator, PRC I.D. No. 0104473 Valid Until: September 19, 2015 Date document is signed: _____________________ Time ______________ Masteral Degree: Master of Science in Nursing

JOSSA ROWENA F. RAMOS RN, MSN Printed Name and Signature Dean, PRC I.D. No. 0253737 Valid Until: December 9, 2013 Date document is signed: _____________________ Time ____________ Masteral Degree: Master of Science in Nursing

Approved by:

PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya Tel. No. (078) 805-3682. Fax No. (078) 321-2397 O.R. CIRCULATING in NUEVA VIZCAYA PROVINCIAL HOSPITAL

ODC Form 2 B O.R CIRCULATING FORM

Prepared by: IRISH JOY P. ANDELEON Name and Signature

Date Performed And Time Started

Patients INITIAL Only _____________ Case Number

SURGICAL PROCEDURE PERFORMED

O.R NURSE ON DUTY (Name and Signature)

SUPERVISEDBY Clinical Instructor Name and Signature

Fidelito H. Salinas, RN, MAN PRC #: 0552433 Validity: February 2, 2015 Date Signed:__________

August 15, 2011 5:15 PM

B. T Case # 10213

Anabelle Agpalasin, RN Open Reduction Internal Fixation (Intramascular Nailing) Tibia Left
Rolina R. Niegas, RN PRC #: 0243424 Validity: February 4, 2014 Date Signed:__________

Henrick John G. Vaquilar, RN March 9, 2012 1:55 PM C.D Case # 3352 Open Reduction Internal Fixation Clavicle Left

Noted by:

CONSTANCIA A. SOUISSI, RN, MSN Printed Name and Signature Clinical Coordinator, PRC I.D. No. 0104473 Valid Until: September 19, 2015 Date document is signed: _____________________ Time ______________ Masteral Degree: Master of Science in Nursing

JOSSA ROWENA F. RAMOS RN, MSN Printed Name and Signature Dean, PRC I.D. No. 0253737 Valid Until: December 9, 2013 Date document is signed: _____________________ Time ____________ Masteral Degree: Master of Science in Nursing

Approved by:

PLT COLLEGE, INC.

Bayombong, Nueva Vizcaya Tel. No. (078) 805-3682. Fax No. (078) 321-2397

DR / OR CASES
Name of Student: IRISH JOY P. ANDELEON

Date Completed: _________________________

CONCURRED BY:
Concurred by: Concurred by: Concurred by: Concurred by:

LUZ F. BARTOLOME, RN, MSN, MAN

Chief Nurse: PLTCI Luis A. Tiam Medical Center Masteral Degree: Master of Science in Nursing Master of Arts in Nursing Date Signed: _________________ PRC No.: 0087504 PNA No.: 16223 ANSAP No.: 101272 Valid Until: 01-13-16 Valid Until: Lifetime Valid Until: Lifetime

ARMIE H. GARCIA, RN, MSN

Chief Nurse: Nueva Vizcaya Provincial Hospital Masteral Degree: Master of Science in Nursing Date Signed: _________________

NELIA M. VICENTE,RN,MAN
Chief Nurse: Veterans Regional Hospital Masteral Degree: Master of Arts in Nursing Date Signed: _________________ Chief Nurse, Nursing Service Department Date Signed: _________________ Masteral Degree

PRC No.: 0137246 PNA No.: 16918 ANSAP No.: 1037

Valid Until: 10-29-13 Valid Until: Lifetime Valid Until: Lifetime

PRC No.: 0090287 PNA No.: 5465 ANSAP No.: 0311

Valid Until: 03-20-15 Valid Until: Lifetime Valid Until: Lifetime

Valid Until: ________ Valid Until: ________ Valid Until: ________

Valid Until: ________ Valid Until: ________ Valid Until: ________