University of the Cordilleras

COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
====================================
==========
OPERATING ROOM SCRUB CASE SLIP:
Major ( ) Minor ( )
Agency: _________________________________________________
Hospital ( )
Community ( ) Medical Mission (
)
Address: ________________________________________________
Name of Patient _________________________________________
Case Number ___________________ Age ______ Gender ______
Operation Performed _____________________________________
____________________________________________________
____________________________________________________
Date of Operation ________________________________________
Time started _____________ Time completed _______________
Scrub Nurse 1___________________________________________
Scrub Nurse 2___________________________________________
Circulating Nurse ________________________________________
Name of OR Nurse ________________________________________
_____________________________________________
Clinical Instructors full Name and signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI:
No erasures
Complete and correct data
Sign in blue pen
UC-VPAA-CON-FORM-20a
JUNE 2012
REV:00

University of the Cordilleras

COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
====================================
==========
OPERATING ROOM CIRCULATING CASE SLIP:
Major ( of
) the
Minor
( )
University
Cordilleras
COLLEGE OF NURSING
Agency: _________________________________________________
Gov. Pack Road, 2600 Baguio City
Hospital ( )
Community ( ) Medical Mission (
=====================================
)
=========
Address:
________________________________________________
DELIVERY
CASE SLIP: Actual ( )
Assist ( )
Name of Patient _________________________________________
Case Number
___________________ Age ______ Gender ______
Agency:
____________________________________________
Operation PerformedHospital
_____________________________________
( )
Home ( ) Birthing/
____________________________________________________
Lying-in
( )
____________________________________________________
Address:
____________________________________________
Date of Operation
________________________________________
Name
Mother ________________________________________
TimeNumber
started___________________
_____________ TimeAge
completed
_______________
Case
____________________
Scrub
1___________________________________________
Type
ofNurse
Delivery
Attended _________________________________
Scrub
Nurse 2___________________________________________
____________________________________________________
Circulating
Nurse ________________________________________
____________________________________________________
Name
OR Nurse
________________________________________
Date
of of
Delivery
_________________________________________
Time of Delivery _____________ Time Placenta Out __________
_____________________________________________
Actual Nurse
___________________________________________
Clinical
Instructors full Name and signature
Assist Nurse
___________________________________________
PRC Number
_______________
Validity ____________________
Name
of DR Nurse/
Midwife _______________________________
PNA Number _______________ Regular ( ) Life Time ( )
_________________________________
CI:
Clinical Instructors full Name and signature
No erasures
Complete
and _______________
correct data
PRC
Number
Validity ____________________
Sign in blue pen

PNA Number _______________ Regular ( ) Life Time (

CI:
UC-VPAA-CON-FORM-20b
No
erasures
JUNE
2012
REV:00
Complete and correct data
Sign in blue pen
UC-VPAA-CON-FORM-20c
JUNE 2012
REV:00

University of the Cordilleras

COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
=====================================
=========

IMMEDIATE NEWBORN CARE CASE SLIP

Agency: ____________________________________________
Hospital ( )
Home ( ) Birthing/ Lying-in
( )
Address: ____________________________________________
Name of Mother ________________________________________
Name of Baby __________________________________________
Date of Delivery_________________ Time ___________________
Case Number ___________________ Gender _________________
Immediate Newborn Care Performed at:
Delivery Room
(
)
Home
(
)
Nursery
(
)
Others _____________________________________
Name of Performing Nurse
___________________________________
Name of DR/ Nursery Nurse /Midwife:
_________________________
__________________________________________
Clinical Instructors full Name and signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI:
No erasures
Complete and correct data
Sign in blue pen
UC-VPAA-CON-FORM-20d