UNIVERSITY OF PERPETUAL HELP RIZAL MOLINO CAMPUS

Molino 3, Bacoor Cavite

(046) 477-1430/477-1630/477-0621/477-0679/477-0602/Fax # 477-0606/www.perpetual.edu.ph
SURGICAL SCRUB in _________________________________________________________________
Hospital/Municipality/City/Province

Prepared by:
Name of Student __________________________________________________ Signature of Student ______________________________

Date Performed SUPERVISED BY

Patient’s Name O.R. Nurse On Duty
and
Case Number PROCEDURE PERFORMED (Name only)
Clinical Instructor
Time Started Name & Signature

Noted by: (Print Name & Signature)
________________________________________
Clinical Coordinator
PRC ID No._______________________Valid Until ________________
PNA No._________________________ Valid Until ________________
Date document is signed________________ Time_________________
Please specify Highest Nursing Degree Earned: __________________
Concurred by: (Print Name & Signature)
___________________________________________
Chief Nurse
PRC ID No.______________________Valid Until _____________
PNA No.________________________ Valid Until _____________
Date document is signed____________ Time_________________
Please specify Highest Nursing Degree Earned:_______________

Approved by: (Print Name & Signature)

____________________________________
Dean
PRC ID No.___________________ Valid Until _______________
PNA No._____________________ Valid Until _______________
ADCPN No.__________________ Valid Until ________________
Date document signed ___________________ Time __________
Please specify Highest Degree Earned _____________________
 UNIVERSITY OF PERPETUAL HELP RIZAL MOLINO CAMPUS
Molino 3, Bacoor Cavite
(046) 477-1430/477-1630/477-0621/477-0679/477-0602/Fax # 477-0606/www.perpetual.edu.ph
ACTUAL DELIVERY in _________________________________________________________________
Hospital/Home/Lying –In Clinic/ Municipality/City/Province
Prepared by:
Name of Student __________________________________________________ Signature of Student ______________________________

Date Performed Patient’s Name D.R. Nurse/Midwife SUPERVISED BY

and Case Number PROCEDURE PERFORMED On Duty Clinical Instructor
(not applicable for
Time Started Birthing/Lying-In Clinics/Homes (Name only) Name & Signature

Noted by: (Print Name & Signature)
________________________________________
Clinical Coordinator
PRC ID No._______________________Valid Until ________________
PNA No._________________________ Valid Until ________________
Date document is signed________________ Time_________________
Please specify Highest Nursing Degree Earned: __________________
Concurred by: (Print Name & Signature)
___________________________________________
Chief Nurse
PRC ID No.______________________Valid Until _____________
PNA No.________________________ Valid Until _____________
Date document is signed____________ Time_________________
Please specify Highest Nursing Degree Earned:_______________

Approved by: (Print Name & Signature)

____________________________________
Dean
PRC ID No.___________________ Valid Until _______________
PNA No._____________________ Valid Until _______________
ADCPN No.__________________ Valid Until ________________
Date document signed ___________________ Time __________
Please specify Highest Degree Earned _____________________
 UNIVERSITY OF PERPETUAL HELP RIZAL MOLINO CAMPUS
Molino 3, Bacoor Cavite
(046) 477-1430/477-1630/477-0621/477-0679/477-0602/Fax # 477-0606/www.perpetual.edu.ph
ASSISTED DELIVERY in _________________________________________________________________
Hospital/Home/Lying –In Clinic/ Municipality/City/Province
Prepared by:
Name of Student __________________________________________________ Signature of Student ______________________________

Date Performed Patient’s Name D.R. Nurse/Midwife SUPERVISED BY

and Case Number PROCEDURE PERFORMED On Duty Clinical Instructor
(not applicable for Birthing/Lying-
Time Started In Clinics/Homes (Name only) Name & Signature

Noted by: (Print Name & Signature)
________________________________________
Clinical Coordinator
PRC ID No._______________________Valid Until ________________
PNA No._________________________ Valid Until ________________
Date document is signed________________ Time_________________
Please specify Highest Nursing Degree Earned: __________________
Concurred by: (Print Name & Signature)
___________________________________________
Chief Nurse
PRC ID No.______________________Valid Until _____________
PNA No.________________________ Valid Until _____________
Date document is signed____________ Time_________________
Please specify Highest Nursing Degree Earned:_______________

Approved by: (Print Name & Signature)

____________________________________
Dean
PRC ID No.___________________ Valid Until _______________
PNA No._____________________ Valid Until _______________
ADCPN No.__________________ Valid Until ________________
Date document signed ___________________ Time __________
Please specify Highest Degree Earned _____________________
 UNIVERSITY OF PERPETUAL HELP RIZAL MOLINO CAMPUS
Molino 3, Bacoor Cavite
(046) 477-1430/477-1630/477-0621/477-0679/477-0602/Fax # 477-0606/www.perpetual.edu.ph

IMMEDIATE NEWBORN CORD CARE in _________________________________________________________________

Hospital/Home/Lying –In Clinic/ Municipality/City/Province
Prepared by:
Name of Student __________________________________________________ Signature of Student ______________________________

Date Performed Patient’s Name Immediate Newborn Cord Care Nurse/Midwife SUPERVISED BY
and Case Number PERFORMED On Duty Clinical Instructor
(not applicable for Indicate where performed e.g. D.R., Nursery, NICU,
Time Started Birthing/Lying-In Clinics/Homes (Name only) Name & Signature
or Home

Noted by: (Print Name & Signature)
________________________________________
Clinical Coordinator
PRC ID No._______________________Valid Until ________________
PNA No._________________________ Valid Until ________________
Date document is signed________________ Time_________________
Please specify Highest Nursing Degree Earned: __________________
Concurred by: (Print Name & Signature)
___________________________________________
Chief Nurse
PRC ID No.______________________Valid Until _____________
PNA No.________________________ Valid Until _____________
Date document is signed____________ Time_________________
Please specify Highest Nursing Degree Earned:_______________

Approved by: (Print Name & Signature)

____________________________________
Dean
PRC ID No.___________________ Valid Until _______________
PNA No._____________________ Valid Until _______________
ADCPN No.__________________ Valid Until ________________
Date document signed ___________________ Time __________
Please specify Highest Degree Earned _____________________