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ODC Form 1A

Actual Delivery Form

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728

ACTUAL DELIVERY in_______________________________________________________________________________________


Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed name and Signature of Student______________________________________________
Date performed
and
Time Started

Patients INITIAL Only

PROCEDURE
PERFORMED

Case Number
(not applicable for birthing/

D.R Nurse On Duty


(Name and Signature)
(If Midwife on Duty,
Signature not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Lying-In Clinics/Homes)

Noted by: ___________________________________


(Print Name and Signature)

Approved by: ____________________________________

Clinical Coordinator, PRC I.D No. _______ Valid Until_______


Date document is signed:________________ Time___________
Please specify Highest Nursing Degree Earned:______________

Dean, PRC I.D No. __________________ Valid Until_____________


Date document is signed:________________ Time________________
Please specify Highest Nursing Degree Earned:___________________

(Print Name and Signature)

(STRICTLY NO DESIGNATES)

ODC Form 1B
Assisted Delivery
Form

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728

ACTUAL DELIVERY in_______________________________________________________________________________________


Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed name and Signature of Student______________________________________________
Date performed
and
Time Started

Patients INITIAL Only

PROCEDURE
PERFORMED

D.R Nurse On Duty


(Name and Signature)
(If Midwife on Duty,
Signature not Required)

Case Number
(not applicable for birthing/
Lying-In Clinics/Homes)

SUPERVISED BY
Clinical Instructor
Name and Signature

ASSISTED DELIVERY

Noted by: ___________________________________


(Print Name and Signature)

Approved by: ____________________________________

Clinical Coordinator, PRC I.D No. _______ Valid Until_______


Date document is signed:________________ Time___________
Please specify Highest Nursing Degree Earned:______________

Dean, PRC I.D No. __________________ Valid Until_____________


Date document is signed:________________ Time________________
Please specify Highest Nursing Degree Earned:___________________

(Print Name and Signature)

(STRICTLY NO DESIGNATES)

ODC Form 1C
Cord Care Form

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728

IMMEDIATE NEWBORN CORD CARE in OSPITAL NG MAYNILA MEDICAL CENTER, MALATE MANILA
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CELESTINO, KEVIN JAN B.
Date performed
and
Time Started

Patients INITIAL Only


Case Number
(not applicable for birthing/

Immediate Newborn Cord Care


PERFORMED

Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Cord Care/Delivery Room

Mariciena Amor C.
Merino R.N.

Rosechelle S.
Elarco R.N. M.A.N.

Cord Care/Delivery Room

Mariciena Amor C.
Merino R.N.

Rosechelle S.
Elarco R.N. M.A.N.

Cord Care/Delivery Room

Mariciena Amor C.
Merino R.N.

Rosechelle S.
Elarco R.N. M.A.N.

(Indicate where performed e.g. DR, Nursery, NICU, or Home)

Lying-In Clinics/Homes)

November 23, 2014

BABY GIRL P.

8:55 pm

690423

November 23, 2014

BABY GIRL A.

9:40 pm

690425

November 24, 2014

BABY GIRL D.

2:58 AM

690427

Noted by: BERNARDITA T. HERNANDEZ R.N. M.A.N. E.d.D.


(Print Name and Signature)

Approved by: ARLENE BLAISE T. CORTEZ R.N. M.A.N. E.d.D.

Level IV Chairman, PRC I.D No.: 0115934Valid Until: August 20, 2015
Date document is signed:________________ Time: ___________
Highest Nursing Degree Earned: B.S.N, M.A.N, E.d.D.

Dean, PRC I.D No.: 0080936 Valid Until: April 6, 2015


Date document is signed:________________ Time: _______________
Highest Nursing Degree Earned:B.S.N, M.A.N, E.d.D.

(Print Name and Signature)

(STRICTLY NO DESIGNATES)

ODC Form 2B
Cord Care Form

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728

SURGICAL SCRUB in OSPITAL NG MAYNILA MEDICAL CENTER, MALATE MANILA


Hospital Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CELESTINO, KEVIN JAN B.
Date performed
and
Time Started

Patients INITIAL Only

August 12, 2014

B.D.S

2:00 pm

2733039

August 19, 2014

R.A.F.D

3:30 pm

1748990

SURGICAL PROCEDURE
PERFORMED

O.R Nurse On Duty


(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Hernioplasty, Right

Christian Lloyd M.
Cabusay R.N.

Arleen E. Monterde
R.N., M.A.N.

Low Transverse Ceasarian Section

Christian Lloyd M.
Cabusay R.N.

Arleen E. Monterde
R.N., M.A.N.

Case Number

Noted by: BERNARDITA T. HERNANDEZ R.N. M.A.N. E.d.D.


(Print Name and Signature)

Approved by: ARLENE BLAISE T. CORTEZ R.N. M.A.N. E.d.D.

Level IV Chairman, PRC I.D No.: 0115934Valid Until: August 20, 2015
Date document is signed:________________ Time: ___________
Highest Nursing Degree Earned: B.S.N, M.A.N, E.d.D.

Dean, PRC I.D No.: 0080936 Valid Until: April 6, 2015


Date document is signed:________________ Time: _______________
Highest Nursing Degree Earned:B.S.N, M.A.N, E.d.D.

(Print Name and Signature)

(STRICTLY NO DESIGNATES)

ODC Form 2B
Cord Care Form

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728

SURGICAL SCRUB in OSPITAL NG MAYNILA MEDICAL CENTER, MALATE MANILA


Hospital Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CELESTINO, KEVIN JAN B.
Date performed
and
Time Started

Patients INITIAL Only

August 12, 2014

J.H.M.A

6:40pm

2731727

August 19, 2014

C.P.C

2 pm

2733977

SURGICAL PROCEDURE
PERFORMED

O.R Nurse On Duty


(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Removal of Foreign Body Impaction, Left Ear

Christian Lloyd M.
Cabusay R.N.

Arleen E. Monterde
R.N. M.A.N.

Thoracentesis

Christian Lloyd M.
Cabusay R.N.

Arleen E. Monterde
R.N. M.A.N.

Case Number

Noted by: BERNARDITA T. HERNANDEZ R.N. M.A.N. E.d.D.


(Print Name and Signature)

Approved by: ARLENE BLAISE T. CORTEZ R.N. M.A.N. E.d.D.

Level IV Chairman, PRC I.D No.: 0115934Valid Until: August 20, 2015
Date document is signed:________________ Time: ___________
Highest Nursing Degree Earned: B.S.N, M.A.N, E.d.D.

Dean, PRC I.D No.: 0080936 Valid Until: April 6, 2015


Date document is signed:________________ Time: _______________
Highest Nursing Degree Earned:B.S.N, M.A.N, E.d.D.

(Print Name and Signature)

(STRICTLY NO DESIGNATES)

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