O.

R Form 1B
O.R. CIRCULATING
FORM Major
ATENEO DE ZAMBOANGA UNIVERSITY
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
SURGICAL SCRUB in ZAMBOANGA DOCTORS HOSPITAL, INC., ZAMBOANGA CITY

Hospital, Municipality/ City/ Province

Prepared by:
Name of Student:ALMARIO, KHADIJAH NUR Signature of Student:__________________________

Date Performed Patients Name SUPERVISED BY:

SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED Name and Signature
Time Started Name and Signature
Case Number

S.E
July 13, 2016 Exploratory laparotomy,
347394 Ms. Angeleen Elizabeth Ms. Eva R. Relao RN, MN
10:45am appendectomy, peritoneal washing
Cortez, RN

Noted by: Approved by:

ANTONIA RENOLLA QUILOS, RN, MN MARIA LORNA BELLO-PABER, RN, MAN
Clinical Coordinator Dean
PRC I.D. No. 0162082 Valid Until: 2016 PRC I.D. No. 0059150 Valid Until: 2016
PNA I.D. No. 2016-004006 Valid Until: 2016 PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2016

Date document is signed: _______________________ Time: ______________ Date document is signed: _____________________ Time: __________
Highest Degree Earned: MASTERS IN NURSING Highest Degree Earned: MASTER OF ARTS IN NURSING