San Juan De Dios Educational Foundation, Inc.

College of Nursing
2772-2774 Roxas Boulevard, Pasay City

Name of Student:
Name & Address of School: SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 ROXAS BOULEVARD, PASAY CITY 1300
Accreditation Level: (if any) CHED ORDER NO. 31, s, LEVEL I Year Granted: 2003
Date School/Program was recognized: JUNE 2, 1975 Number: 278 Year: 1975
First Course (if any): School Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program: 2005
Year Graduated (BSN Program): 2011

I. MAJOR OPERATIONS
Signature of
No. Date of Case No. Name of Patient Diagnosis Operation Type of Name of Surgeon Name of Hospital Name of OR OR Scrub
Operation Performed Anesthesia Scrub Nurse Nurse
January 28, 268355 Roa, Emilio Acute calculous Cholecystitis Subarachnoid Dr. A. Santos San Juan De Dios Shannon
1 2010 cholecystitis with block, Hospital Tuvida, RN
intraoperative continuous
cholangigraphy, epidural
common bile anesthesia
duct exploration

Concurred by: Approved by: Noted by:

MR. RODOLFO C. BORROMEO, RN, MAN SR. HEIDI A. FACTO,DC MRS. MA. ESTRELLA CAOILI, RN, MAN
Signature over printed name of Chief Nurse Signature over printed name of Dean Signature over printed name of Clinical Coordinator
Date Signed: Date Signed: Date Signed:
Degree: RN, MAN Degree: RN, MAN Degree: RN, MAN
a) PRC No. a) PRC No. a) PRC No.
Valid until: Valid until: Valid until:
b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid until:
c) ADPCN No.
 Valid until: Prepared by: _________________________________

San Juan De Dios Educational Foundation, Inc.

College of Nursing
2772-2774 Roxas Boulevard, Pasay City
Name of Student:
Name & Address of School: SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 ROXAS BOULEVARD, PASAY CITY 1300
Accreditation Level: (if any) CHED ORDER NO. 31, s, LEVEL I Year Granted: 2003
Date School/Program was recognized: JUNE 2, 1975 Number: 278 Year: 1975
First Course (if any): School Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program: 2005
Year Graduated (BSN Program): 2011

II. MINOR OPERATIONS

Signature of OR
No. Date of Case No. Name of Patient Diagnosis Operation Performed Type of Name of Surgeon Name of Hospital Name of OR Scrub Nurse
Operation Anesthesia Scrub Nurse
Jerwin
1 July 3, 2010 READ Ma. Fe Sula Tupas Multiple dental Tooth extraction Local Dr. Rosalina- San Juan De Dios Manalastas,
Carries Marato Ignacio Hospital RN

Concurred by: Approved by: Noted by:

MR. RODOLFO C. BORROMEO, RN, MAN SR.HEIDI A. FACTO, DC MRS. MA. ESTRELLA T. CAOILI, RN, MAN
Signature over printed name of Chief Nurse Signature over printed name of Dean Signature over printed name of Clinical Coordinator
Date Signed: Date Signed: Date Signed:
Degree: RN, MAN Degree: RN, MAN Degree: RN, MAN
a) PRC No. a) PRC No. a) PRC No.
Valid until: Valid until: Valid until:
b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid until:
 c) ADPCN No.
Valid until: Prepared by: _________________________________

San Juan De Dios Educational Foundation, Inc.

College of Nursing
2772-2774 Roxas Boulevard, Pasay City

Name of Student: ______________________________________________

Name & Address of School: SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 ROXAS BOULEVARD, PASAY CITY 1300
Accreditation Level: (if any) CHED ORDER NO. 31, s, LEVEL I Year Granted: 2003
Date School/Program was recognized: JUNE 2, 1975 Number: 278 Year: 1975
First Course (if any): School Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program: 2005
Year Graduated (BSN Program): 2011

III. ACTUAL DELIVERIES

Supervised by:
No. Case No. Diagnosis Name of Mother Age Date of Delivery Time of Gender Name of Hospital Type of Name & Signature of
Delivery of Baby Delivery Qualified CI
Pregnancy Uterine Natural Marianne
1 222100 Cephalic in Labor Jennievee April 18 y/o April 20,2010 11:56am girl Ospital ng Sampaloc spontaneous Montemayor, RN
G1P0 Damian delivery

Concurred by: Approved by: Noted by:

MRS. MARIE THERESE A. PACABIS, RN, RM, MAN SR. HEIDI A. FACTO, DC MRS. MA. ESTREALLA T. CAOILI, RN, MAN
Signature over printed name of Chief Nurse Signature over printed name of Dean Signature over printed name of Clinical Coordinator
Date Signed: Date Signed: Date Signed:
Degree: RN, RM, MAN Degree: RN, MAN Degree: RN, MAN
a) PRC No. a) PRC No. a) PRC No.
Valid until: Valid until: Valid until:
b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid until:
c) ANSAP No. c) ADPCN No.
Valid until: Valid until: Prepared by: _________________________________
 San Juan De Dios Educational Foundation, Inc.
College of Nursing
2772-2774 Roxas Boulevard, Pasay City

Name of Student:
Name & Address of School: SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 ROXAS BOULEVARD, PASAY CITY 1300
Accreditation Level: (if any) CHED ORDER NO. 31, s, LEVEL I Year Granted: 2003
Date School/Program was recognized: JUNE 2, 1975 Number: 278 Year: 1975
First Course (if any): School Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program: 2005
Year Graduated (BSN Program): 2011
IV. DELIVERIES ASSISTED
Supervised by:
No. Case No. Diagnosis Name of Patient Age Date of Delivery Time of Gender Name of Hospital Type of Name & Signature of
Delivery of Baby Delivery Qualified CI

Concurred by: Approved by: Noted by:

MRS. MARIE THERESE A. PACABIS, RN, RM, MAN SR. HEIDI A. FACTO, DC MRS. MA. ESTRELLA T. CAOILI, RN, MAN
Signature over printed name of Chief Nurse Signature over printed name of Dean Signature over printed name of Clinical Coordinator
Date Signed: Date Signed: Date Signed:
Degree: RN, RM, MAN Degree: RN, MAN Degree: RN, MAN
a) PRC No. a) PRC No. a) PRC No.
Valid until: Valid until: Valid until:
b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid until:
c) ANSAP No. c) ADPCN No.
Valid until: Valid until: Prepared by: ________________________________

San Juan De Dios Educational Foundation, Inc.

College of Nursing
2772-2774 Roxas Boulevard, Pasay City

Name of Student:
Name & Address of School: SAN JUAN DE DIOS EDUCATIONAL FOUNDATION, INC.
2772-2774 ROXAS BOULEVARD, PASAY CITY 1300
Accreditation Level: (if any) CHED ORDER NO. 31, s, LEVEL I Year Granted: 2003
Date School/Program was recognized: JUNE 2, 1975 Number: 278 Year: 1975
First Course (if any): School Graduated From: Year:
Year of Admission in the Bachelor of Science in Nursing Program: 2005
Year Graduated (BSN Program): 2009

V. CORD DRESSING
Supervised by:
No. Case No. Date Performed Name of Baby Gender of Name of Mother Age Name of Hospital Name & Signature of
Baby Qualified CI
Paranaque community
1 35068 July 7, 2009 Bb. Boy Principal Boy Mylen Principal 38 y/o Hospital Nedly Lozano, RN

Concurred by: Approved by: Noted by:

MRS. MARIE THERESE A. PACABIS, RN, RM, MAN SR. HEIDI A. FACTO, DC MRS. MA. ESTRELLA T. CAOILI, RN, MAN
Signature over printed name of Chief Nurse Signature over printed name of Dean Signature over printed name of Clinical Coordinator
Date Signed: Date Signed: Date Signed:
Degree: RN, RM, MAN Degree: RN, MAN Degree: RN, MAN
a) PRC No. a) PRC No. a) PRC No.
Valid until: Valid until: Valid until:
b) PNA No. b) PNA No. b) PNA No.
Valid until: Valid until: Valid until:
c) ANSAP No. c) ADPCN No.
Valid until: Valid until: Prepared by: