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O.

R Form 1B
O.R. CIRCULATING
ATENEO DE ZAMBOANGA UNIVERSITY FORM Minor
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 SURGICAL PROCEDURE O.R. Nurse On Duty


SUPERVISED BY:
and Clinical Instructor
PERFORMED Name and Signature
Time Started Name and Signature
Case Number

July 12, 2016 G.B Mrs. Eva R. Relao RN, MN


Gastroscopy Ms. Angeleen Elizabeth
9:30AM 114126
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