ODC Form 1A

ACTUAL DELIVERY
FORM
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
ACTUAL DELIVERY in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

Prepared by: DIANE CHRISTINE P. CORNELIA

(Printed Name with Signature)

Patients INITIALS(only)
Date Performed
and
Time Started

PROCEDURE
PERFORMED

December 12,2015
(4:40 PM)

Case Number
(not applicable for
Birthing/Lying-in
Clinics/Homes)
LML
255782

January 31, 2016

(1:10PM)

MA
260661

Normal Spontaneous Vaginal Delivery

March 19, 2016

(4:32PM)

RLT
265606

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

D.R Nurse On Duty

(Name and Signature)
(If midwife on duty,
Signature Not Required)

JUDITH DENILA,RN,MAN
PRC
MERLITA OMLERO,RN
PRC 0101442
JUDITH DENILA,RN,MAN
PRC

SUPERVISED BY
Clinical Instructor
Name and Signature

ELVIE PALER, RN, MAN

PRC NO. 193311
LYNUEL R. SANTILLANA,RN,MAN
PRC 0382115
LYNUEL R. SANTILLANA,RN,MAN
PRC 0382115

Noted by:

Approved by:

(Print Name and Signature)

Clinical Coordinator, PRC I.D No.
Valid Until:
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

(Print Name and Signature)

Dean, PRC I.D No.
Valid Until :
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

ODC Form 1B
ASSISTED
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

DELIVERY FORM

ACTUAL DELIVERY in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

Prepared by: DIANE CHRISTINE P. CORNELIA

(Printed Name with Signature)

Patients INITIALS(only)
Date Performed
and
Time Started

PROCEDURE
PERFORMED

December 9, 2015
(8:10 PM)

Case Number
(not applicable for
Birthing/Lying-in
Clinics/Homes)
CAM
255352

December 22, 2015

(7:40 AM)

MN
256659

Normal Spontaneous Vaginal Delivery

April,16,2016
(5:10 PM)

KKC
268146

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

D.R Nurse On Duty

(Name and Signature)
(If midwife on duty,
Signature Not Required)

JUDITH DENILA, MAN, RN

PRC
ANNA MAE ADAMAT
PRC
MERLITA OMLERO
PRC

SUPERVISED BY
Clinical Instructor
Name and Signatusre

LYNUEL R. SANTILLANA,RN,MAN
PRC 0382115
GLORIA SHIELA COYOCA,RN,MAN
PRC 0256493
CARMELA D. ORTEGA,RN,MAN
PRC 0390177

Noted by:

Approved by:

(Print Name and Signature)

Clinical Coordinator, PRC I.D No.
Valid Until:
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

(Print Name and Signature)

Dean, PRC I.D No.
Valid Until :
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

ODC Form 1C
CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

Prepared by : DIANE CHRISTINE P. CORNELIA

(Printed Name with Signature)

Patients INITIALS(only)
Date Performed
and
Time Started
Case Number
(not applicable for Birthing/Lyingin Clinics/Homes)

Immediate Newborn Cord Care

PERFORMED
Indicate where performed e.g.
D.R., Nursery, NICU, or Home

()

Bb Girl N
255651

Immediate Newborn and Cord

Care

()

Bb Girl G
256683

Immediate Newborn and Cord

Care

()

Bb Boy D
271525

Immediate Newborn and Cord

Care

Nurse On Duty
(Name and Signature)
(If midwife on duty,
Signature Not Required)

Mignonette Ross N. Galope,RN

PRC 660208
Mignonette Ross N. Galope,RN
PRC 660208
Mignonette Ross N. Galope,RN
PRC 660208

SUPERVISED BY
Clinical Instructor
Name and Signature

ELVIE A. PALER, MAN, RN

PRC NO. 193311
GLORIA SHIELA COYOCA,RN,MAN
PRC 0256493
LYNUEL R. SANTILLANA, MAN, RN
PRC NO. 382115

Noted by:

Approved by:

(Print Name and Signature)

Clinical Coordinator, PRC I.D No.
Valid Until:
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

(Print Name and Signature)

Dean, PRC I.D No.0369698
Valid Until :
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

ODC Form 2A
O.R. SCRUB
FORM Major

SURGICAL SCRUB in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

Prepared by: DIANE CHRISTINE P. CORNELIA

(Printed Name with Signature)

Patients INITIALS(only)
Date Performed
and
Time Started

SURGICAL PROCEDURE
PERFORMED

O.R Nurse On Duty

(Name and Signature)

Case Number

SUPERVISED BY
Clinical Instructor
Name and Signature

Noted by:

Approved by:

(Print Name and Signature)

Clinical Coordinator, PRC I.D No.
Valid Until:
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

(Print Name and Signature)

Dean, PRC I.D No.
Valid Until :
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

ODC Form 2B
O.R. CIRCULATING
FORM

SURGICAL SCRUB in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

Prepared by: DIANE CHRISTINE P. CORNELIA

(Printed Name with Signature)

Date Performed
and
Time Started

Patients
INITIALS(only)
Case Number

SURGICAL
PROCEDURE
PERFORMED

O.R Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Noted by:

Approved by:

(Print Name and Signature)

Clinical Coordinator, PRC I.D No.
Valid Until: April 15, 2017
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

(Print Name and Signature)

Dean, PRC I.D No.
Valid Until :
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING