Southwestern University - PRC Format

ODC Form 2A
O.R. SCRUB FORM

Republic of the Philippines Major
Professional Regulation Commission
Board of Nursing
SOUTHWESTERN UNIVERSITY
College of Nursing
Villa Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email Address: swu.nursing@gmail.com
SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER___________________________________

Hospital, Municipality / City / Province
Prepared by:
Printed Name and Signature of Student RHENA LOU G. BONOTAN_________________
Date Performed SUPERVISED BY

Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty
and Clinical Instructor
PERFORMED (Name AND Signature)
Time Started Name and Signature
Case Number
July 21, 2009 P. L. P.
08:20 am 58721 Left Hydrocoelectomy JESUSA M. COLOSCOS, RN ERGIE P. INOCIAN, RN, MSN
July 21, 2009 A. E. Exploratory Laparotomy
09:10 am 51035 Bladder Biopsy (Core Needle) LILIBETH L. PUNAY, RN ERGIE P. INOCIAN, RN, MSN
July 22, 2009 G. I. S. Debridement, Application of
07:50 am 57453 External-Fixator, Pining LILIAN S. DELGADO, RN ERGIE P. INOCIAN, RN, MSN
Noted by: RAMON PERLEY M. PANDAAN Approved by: LUCRIS A. TAN JR.
OR/DR Clinical Coordinator, PRC I.D. No. 0243199 Valid Until July 8, 2010 Dean, PRC I.D. No. 0285376 Valid Until April 9, 2012
Date document is signed:________Time____________ Date document is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MD, MAN
(STRICTLY NO DESIGNATES)
ODC Form 2A
O.R. SCRUB FORM
Republic of the Philippines Major
Board of Nursing
College of Nursing
SURGICAL SCRUB in SACRED HEART HOSPITAL_________________________________________________

Prepared by:

Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty
PERFORMED (Name AND Signature)
Case Number
August 29, 2008 A.C. C. Peripheral Iridectomy, Right
10:00 am 437846 eye JACQUELINE ANNE D. FUENTES, RN RISA P. CHUA, RN, MAN
September 09, 2008 P. V. N. Extracapsular Cataract
08:30 am 486827 Extraction with Posterior
Chamber Intraocular lens MERIAM P. CALLEDO, RN RISA P. CHUA, RN, MAN
Republic of the Philippines ODC Form 2B
Professional Regulation Commission O.R. SCRUB MINOR
Board of Nursing
College of Nursing
SURGICAL SCRUB in LAPU-LAPU CITY DISTRICT HOSPITAL__________________________________________

Prepared by:
Patient’s INITIAL only

SURGICAL PROCEDURE O.R. Nurse On Duty
Case Number PERFORMED (Name and Signature)
July 04, 2008 M. R. L. C. Suturing of Right

08:10 am 0625952 Eyebrow JASMIN B. FUFUNAN, RN CHRISTINE L. PONO, RN, MAN
Board of Nursing
College of Nursing
SURGICAL SCRUB in BARANGAY SAN NICOLAS HEALTH CENTER_______________________________________

Prepared by:

April 24, 2009 M. A.

09:10 am OPD Circumcision MERCEDES JANE P. SIA, RN THELMA R. FELICIANO, RN, MAN,
Ph.D
April 24, 2009 L. M. N.
09:45 am OPD Circumcision MERCEDES JANE P. SIA, RN THELMA R. FELICIANO, RN, MAN,
Ph.D
Board of Nursing
College of Nursing
SURGICAL SCRUB in SACRED HEART HOSPITAL___________________________________________________

Prepared by:

August 07, 2009 A.S. G.

01: 25 pm 516343 No Scalpel Vasectomy MYRNA H. DANUCO, RN ERLINDA C. FERNAN, RN, MAN
Board of Nursing
College of Nursing
SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER____________________________________

Prepared by:
Printed Name and Signature of Student RHENA LOU G. BONOTAN__________________

November 13, 2009 M. F. A Excision of Mass in the

8:53 am 89468 Left Arm Posterior aspect MARIVIC A. DUMAGUING, RN CORAZON B. DUMADAG, RN, MAN
ODC Form 1B
Republic of the Philippines ASSISTED DELIVERY FORM
Board of Nursing
College of Nursing
ACTUAL DELIVERY in SACRED HEART HOSPITAL_________________________________________________

Hospital / Home / Lying-In Clinic, Municipality / City / Province
Prepared by:
Printed Name and Signature of Student RHENA LOU G. BONOTAN___________________
Patient’s INITIAL only PROCEDURE

Date Performed D.R. Nurse/Midwife On Duty SUPERVISED BY
PERFORMED
and (Name and Signature) Clinical Instructor
Case Number ASSISTED DELIVERY
September 13, 2008 J. M. B. Normal Spontaneous Vaginal

08:50 am 475817 Delivery JACQUELINE ANNE D.
FUENTES, RN RISA P. CHUA, RN, MAN
May 03, 2009 M. J. H. N. Normal Spontaneous Vaginal
10:30 pm 497747 Delivery ROXANNE M. PAJULIO, RN RISA P. CHUA, RN, MAN
ODC Form 1B
Board of Nursing
College of Nursing
ACTUAL DELIVERY in OPON PUERICULTURE CENTER AND MATERNITY HOUSE, Inc.______________________

Prepared by:
Printed Name and Signature of Student RHENA LOU G. BONOTAN___________________

PERFORMED
March 22, 2009 C. P. A. Normal Spontaneous Vaginal

01:25 am 20827 Delivery CIPRIANA N. FERNANDEZ, RN JILL MARIE C. HERMOGENES, RN,
MAN
ODC Form 1B
Board of Nursing
College of Nursing
ACTUAL DELIVERY in TALISAY DISTRICT HOSPITAL______________________________________________

Prepared by:

PERFORMED
September 15, 2009 J. C. P. Normal Spontaneous Vaginal

09:10 am 076633 Delivery AGNES D. CABAÑERO, RN THELMA R. FELICIANO, RN, MAN, Ph.D
ODC Form 1B
Board of Nursing
College of Nursing
ACTUAL DELIVERY in TALAMBAN LYING-IN CLINIC_______________________________________________

Prepared by:

PERFORMED
December 21, 2009 A.G. C. Normal Spontaneous Vaginal

02:20 pm 093172 Delivery ELMA L. DUNGOG, RN AMALIA L. MARTINEZ, RN, MAN
ODC Form 1A
ACTUAL DELIVERY FORM
Republic of the Philippines
Board of Nursing
College of Nursing
ACTUAL DELIVERY in OPON PUERICULTURE CENTER AND MATERNITY HOUSE, Inc._________________________

Prepared by:
Patient’s INITIAL (only)

SUPERVISED BY
Date Performed and PROCEDURE D.R. Nurse/Midwife On Duty
Clinical Instructor
Time Started PERFORMED (Name and Signature)
Name and Signature
Case Number
April 16, 2009 G. D. L. Normal Spontaneous

07:40 am 21092 Vaginal Delivery EFREBERNIE B. DICO, RN CHRISTINE L. PONO, RN, MAN
ODC Form 1A
Board of Nursing
College of Nursing
ACTUAL DELIVERY in SACERED HEART HOSPITAL _________________________

Prepared by:

SUPERVISED BY
Clinical Instructor
Name and Signature
Case Number
May 07, 2009 L. F. B. Normal Spontaneous

04:48 am 499586 Vaginal Delivery ROXANNE M. PAJULIO, RN RISA P. CHUA, RN, MAN
ODC Form 1A
Board of Nursing
College of Nursing
ACTUAL DELIVERY in TALAMBAN LYING-IN CLINIC___________________________________________________

Prepared by:

SUPERVISED BY
Clinical Instructor
Name and Signature
Case Number
December 10, 2009 M. C. C. Normal Spontaneous

03:38 am 093154 Vaginal Delivery AIDA B. KAPUNO, RM AMALIA L. MARTINEZ, RN, MAN
December 21, 2009 L. S. L. Normal Spontaneous
03:38 am 093169 Vaginal Delivery ELMA L. DUNGOG, RN AMALIA L. MARTINEZ, RN, MAN
December 21, 2009 A. A. O. Normal Spontaneous
05:40 am 093171 Vaginal Delivery ELMA L. DUNGOG, RN AMALIA L. MARTINEZ, RN, MAN
ODC Form 1C
Republic of the Philippines IMMEDIATE NEWBORN CORD
Professional Regulation Commission CARE
Board of Nursing
College of Nursing
IMMEDIATE NEWBORN CORD CARE in SACRED HEART HOSPITAL___________________________________________________

Prepared by:
Patient’s INITIAL only Immediate Newborn Cord Care

PERFORMED
Indicate where performed e.g. D.R.,
Case Number Nursery, NICU, or Home
August 25, 2008 J. R. G. R.

01:05 pm 485391 Delivery Room MERIAM P. CALLEDO, RN RISA P. CHUA, RN, MAN
May 09, 2009 M. F. L. B.
07:25 am 506860 ROXANNE M. PAJULIO,
Delivery Room RN RISA P. CHUA, RN, MAN
ODC Form 1C
Republic of the Philippines IMMEDIATE NEWBORN CORD
Professional Regulation Commission CARE
Board of Nursing
College of Nursing
IMMEDIATE NEWBORN CORD CARE in TALAMBAN LYING-IN CLINIC__________________________________________________

Prepared by:
Patient’s INITIAL only Immediate Newborn Cord Care

PERFORMED
Indicate where performed e.g. D.R.,
Case Number Nursery, NICU, or Home
December 20, B. F. M.
2009 093167 MA. LIGAYA P.
06:30 am Delivery Room FERNANDEZ, RM AMALIA L. MARTINEZ, RN, MAN
December 20, B. F. L.
2009 093168
12: 45 pm Delivery Room ELMA L. DUNGOG, RM AMALIA L. MARTINEZ, RN, MAN
December 21, R. A. V.
2009 093170
01:50 am Delivery Room AIDA B. KAPUNO, RM AMALIA L. MARTINEZ, RN, MAN

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ODC Form 2A

O.R. SCRUB FORM

SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER___________________________________

Date Performed SUPERVISED BY

SURGICAL SCRUB in SACRED HEART HOSPITAL_________________________________________________

Date Performed SUPERVISED BY

SURGICAL SCRUB in LAPU-LAPU CITY DISTRICT HOSPITAL__________________________________________

Patient’s INITIAL only

July 04, 2008 M. R. L. C. Suturing of Right

SURGICAL SCRUB in BARANGAY SAN NICOLAS HEALTH CENTER_______________________________________

Patient’s INITIAL only

April 24, 2009 M. A.

SURGICAL SCRUB in SACRED HEART HOSPITAL___________________________________________________

Patient’s INITIAL only

August 07, 2009 A.S. G.

SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER____________________________________

Patient’s INITIAL only

November 13, 2009 M. F. A Excision of Mass in the

ACTUAL DELIVERY in SACRED HEART HOSPITAL_________________________________________________

Patient’s INITIAL only PROCEDURE

September 13, 2008 J. M. B. Normal Spontaneous Vaginal

ACTUAL DELIVERY in OPON PUERICULTURE CENTER AND MATERNITY HOUSE, Inc.______________________

Patient’s INITIAL only PROCEDURE

March 22, 2009 C. P. A. Normal Spontaneous Vaginal

ACTUAL DELIVERY in TALISAY DISTRICT HOSPITAL______________________________________________

Patient’s INITIAL only PROCEDURE

September 15, 2009 J. C. P. Normal Spontaneous Vaginal

ACTUAL DELIVERY in TALAMBAN LYING-IN CLINIC_______________________________________________

Patient’s INITIAL only PROCEDURE

December 21, 2009 A.G. C. Normal Spontaneous Vaginal

ACTUAL DELIVERY in OPON PUERICULTURE CENTER AND MATERNITY HOUSE, Inc._________________________

Patient’s INITIAL (only)

April 16, 2009 G. D. L. Normal Spontaneous

ACTUAL DELIVERY in SACERED HEART HOSPITAL _________________________

Patient’s INITIAL (only)

May 07, 2009 L. F. B. Normal Spontaneous

ACTUAL DELIVERY in TALAMBAN LYING-IN CLINIC___________________________________________________

Patient’s INITIAL (only)

December 10, 2009 M. C. C. Normal Spontaneous

IMMEDIATE NEWBORN CORD CARE in SACRED HEART HOSPITAL___________________________________________________

Patient’s INITIAL only Immediate Newborn Cord Care

August 25, 2008 J. R. G. R.

IMMEDIATE NEWBORN CORD CARE in TALAMBAN LYING-IN CLINIC__________________________________________________

Patient’s INITIAL only Immediate Newborn Cord Care

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