MARIANO MARCOS STATE UNIVERSITY

Brgy. 16-S Quiling Sur, Batac City

(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1A
O.R. SCRUB FORM
Prepared by: Major
Printed Name and Signature of Student: JOHN LESTER M. FERNANDEZ

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
September 27, 2016 Alfred G. Epidural Craniotomy G. Bagarra Prof. Flordeliza I. Tabaniag
11:11 AM

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1A
O.R. SCRUB FORM
Prepared by: Major
Printed Name and Signature of Student: JOHN LESTER M. FERNANDEZ

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
October 24, 2016 Kimberly Z.A Hemorrhoidectomy A. Yadao Prof. Flordeliza I. Tabaniag
8:50 AM

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1A
O.R. SCRUB FORM
Prepared by: Major
Printed Name and Signature of Student: JOHN LESTER M. FERNANDEZ

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
October 24, 2016 Emmanuel A. Removal of Implant O. Sadora Prof. Flordeliza I. Tabaniag
1:55 PM

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1A
O.R. SCRUB FORM
Prepared by: Major
Printed Name and Signature of Student: JOHN LESTER M. FERNANDEZ

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
November 28, 2016 Constantino C. TURP R. Oducayen Prof. Flordeliza I. Tabaniag
1:40 PM

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1A
O.R. SCRUB FORM
Prepared by: Major
Printed Name and Signature of Student: JOHN LESTER M. FERNANDEZ

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
Maridel M. R Cesarean E. Cerano Mr. L. Pagdilao
5:35

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1B
O.R. CIRCULATING FORM
Prepared by:
Printed Name and Signature of Student:

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
October 24, 2016 Clamita C. Excision Biopsy O. Sadora Prof. Flordeliza I. Tabaniag
12:15 PM

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

O.R. Form 1B
O.R. CIRCULATING FORM
Prepared by:
Printed Name and Signature of Student:

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
November 29, 2016 Ramie O. Pinning O. Sadora Prof. Flordeliza I. Tabaniag
9:18 AM

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

D.R. Form
ACTUAL DELIVERY
Prepared by: ROOM
Printed Name and Signature of Student:

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

D.R. Form
ASSIST DELIVERY ROOM
Prepared by:
Printed Name and Signature of Student:

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education
 MARIANO MARCOS STATE UNIVERSITY
Brgy. 16-S Quiling Sur, Batac City
(077) 670-1920; mmsuchs2009@yahoo.com;www.mmsu.edu.ph
(Accrediting Agency of Chartered Colleges & Universities in the Philippines (AACUP),INC.)
Level III Re-Accredited; Inclusive Date of Accreditation: November 1, 2010-October 31, 2014

SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL & MEDICAL CENTER BATAC CITY
Hospital/Home/Lying-In Clinic, Municipality/City/Province

ICNB Form
IMMEDIATE CARE OF THE
Prepared by: NEWBORN FORM
Printed Name and Signature of Student:

Date Performed Patients INITIAL SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
And only (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number
December 4, 2015

Noted by: NORMA L. ECLARIN, RN, MAN Approved by: MANOLITA S. CRISOSTOMO, RN, MAN, EdD
Clinical Coordinator, PRC I.D No. 0054871 Valid Until: Dean, PRC I.D No. 0121749 Valid Until: 08/24/2014
PNA No. 17665 Valid Until: Lifetime Member PNA No. 19854 Valid Until: Lifetime Member
Date document is signed: Time: ADPCN No. 11-546 Valid Until:
Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Please specify Highest Nursing Degree Earned: Doctor of Education