PRC Form

REPUBLIC OF THE PHILIPPINES
PROFESSIONAL REGULATION COMMISSION

Manila
Name of Student: Flor Anne D. de Jesus_______________________________________________________________________________________________________________________________

Name and Address of School: Far Eastern University, Nicanor Reyes St. Sampaloc, Manila _
Accreditation Level (if any): Level III PAASCU Re-accredited Year Granted: March 21, 2006 _
Date School/Program was Recognized: April 10, 1958 Number: 66 Year: 1958 _
First Course (if any): None School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated (BSN Program): 2011
I. Major Operations
Supervised by:
Date of Name of Name of O.R. Signature of
No. Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Hospital
Operation Surgeon Scrub Nurse OR/DR
Supervisor
Excision of mass with
Jose Reyes
January Paz San Felipe Frozen Section Edgardo de Villa,
1. 606922 Breast Mass General Anesthesia Memorial Medical Lorefel Lopez, RN Danofrata
8,2011 Balajadia possible Modified MD
Center
Radical Mastectomy
Exlaporatory Right
Jose Reyes
January Ectopic Pregnancy 6-7 weeks Age of Gestation Salphingectomy with Sarah Abiqui, Annaliza Javier,
2. 608888 Edna Galdal General Anesthesia Memorial Medical Danofrata
15,2011 Ruptured Contralateral Tubal MD RN
Center
Ligation
Jose Reyes
January Open Cerclage, Luzviminda
3. 609556 Angelita Bartolome Patellar Fracture, Right General Anesthesia Legazpi,MD Memorial Medical Danofrata
21,2011 Wiring Right Malong, RN
Center
Craniotomy Jose Reyes

January Dindo Coching Rosalie Santos,
4. 609165 To consider Traumatic Brain Iinjury Evacuation of General Anesthesia Khalil Ibaoc, MD Memorial Medical Danofrata
21,2011 Galvero RN
Hematoma Center
Jose Reyes
January Emergency Edgardo de Villa,
5. 545256 Benedicta Sebastian Not Available General Anesthesia Memorial Medical Hilda Duran, RN Danofrata
26,2011 Cholecystectomy MD
Center
Noted by: _________________________________________________

_____________________________________ _________________________________________________ Signature over printed name of Dean
_________________________________________________ Signature over printed name of Chief Nurse Signature over printed name of Date Signed: ______________________________________
Signature over printed name of Chief Nurse Date Signed: ______________________________________ Clinical Coordinator Degree:__________________________________________
Date Signed: ______________________________________ Degree:__________________________________________ Date Signed: ______________________________________ a.) PRC NO: _____________________________________
Degree:__________________________________________ a.) PRC NO: _____________________________________ Degree:__________________________________________ Valid Until:
a) PRC NO: _____________________________________ Valid Until: a.) PRC NO: _____________________________________ _________________________________________
Valid Until: _____________________________________ _________________________________________ Valid Until: _____________________________________ b.) PNA NO: ______________________________________
b.) PNA NO: ______________________________________ b.) PNA NO: ______________________________________ b.) PNA NO: ______________________________________ Valid Until: ____________________________________
Valid Until: ____________________________________ Valid Until: ____________________________________ Valid Until: ____________________________________ c.) ADPCN NO:____________________________________
Valid Until: _____________________________________
Manila
Name of Student: Monique Isah S. de Belen______________________________________________________________________________________________________________________________

Year Graduated (BSN Program): 2011_________________________________________________________________________________________________________________________________
II. Minor Operations

Supervised by:
Date of Name of O.R. Signature of
No. Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital
Operation Scrub Nurse OR/DR
Supervisor
February 8, Pneumo Insertion of Chest tube Taguig Pateros Antonio Santos Lita Bacudio,
1. 10-0363 Ryan Comcom Local Anesthesia Morales, MD
2010 Hemothorax Left Thoracostomy Left District Hospital Jr., RN RN, MAN
Gravid 3 Parity 2
(2012) Incomplete
February 22, Abortion 12 weeks Taguig Pateros Lita Bacudio,
2. 10-0454 Mary Grace Borja Completion Curettage IV Sedation Ampil, MD Ernie
2010 Age of Gestation District Hospital RN, MAN
Non-Septic, Non-
Induced
Esophagogastro
December 20, Peptic Ulcer and Armada Cargo, Irene Latosa,
3. 09-2628 Federico Duque duodenoscopy and IV Sedation Ray Sarmiento, MD Rizal Medical Center
2010 Sigmoid Ulcer RN RN, MAN
Colonoscopy
Status Post
Emergency
Exploratory
December 21, Central Venous Irene Latosa,
4. 09-3703 Reynaldo Lopez Laparotomy, Local Anesthesia Sigrid James Yap, MD Rizal Medical Center Cecilia Sube, RN
2010 Pressure Insertion RN, MAN
Graham Patching
and Jackson Pratt
Drain
December 22, Emergency Benedicto Josef, Irene Latosa,

5. 09-3749 Arianne Mae Rodolfo Acute Appendicitis Local Anesthesia Reigelson Mariano, MD Rizal Medical Center
2010 Appendecitis RN RN, MAN
Noted by: _____________________________________ _________________________________________________ Signature over printed name of Dean

_________________________________________________________________________________
Signature over printed name of Chief Nurse Signature over printed name of Date Signed: ______________________________________
Date Signed: ______________________________________ Degree:__________________________________________ Date Signed: ______________________________________ a.) PRC NO: ______________________________________
Degree:__________________________________________ a.) PRC NO: ______________________________________ Degree:__________________________________________ Valid Until:
a.) PRC NO: ______________________________________ Valid Until: a.) PRC NO: ______________________________________ _________________________________________
Valid Until: _____________________________________
_________________________________________________
Manila

III. Actual Deliveries

Date of Time of Gender of Supervised by: Signature of
No. Case No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery
Delivery Delivery Baby OR/DR Supervisor
Gravida 2 Parity 1 Term 1, Normal
December 17, Camarin Health Normal Spontaneous
1. 444-09 Spontaneous Delivery, delivered to an Mary Joy Gallardo 19 12:00 pm Female Regina Sevilla, RN, MAN
2009 Center and Lying-In Delivery
alive baby girl
10-0373 Gravida 1 Parity 1 (1001) Pregnancy Mary Grace Flores 16 February 9, 7:46 pm Female Taguig Pateros District Normal Spontaneous Lita Bacudio, RN, MAN
Uterine 40 weeks Age of Gestation, 2010 Hospital Delivery
2.
Cephalic in Labor
10-0417 Gravida 1 Parity 1 (1001) Pregnancy Rechie Apostol 22 February 15, 11:25 pm Male Taguig Pateros District Normal Spontaneous Lita Bacudio, RN, MAN
Uterine 38-39 weeks Age of Gestation, 2010 Hospital Delivery
3.
Cephalic in Labor
104-93 Gravida 2 Parity 1 Pregnancy Uterine 38- Ma. Villet de Rama 19 June 11, 2010 10:43 am Female CSV Maternity and Normal Spontaneous Cristina S. Velasquez, RM
39 weeks Age of Gestation, Cephalic in Lying-In Clinic Delivery
4.
Labor
107-08 Gravida 1 Parity 0 Pregnancy Uterine 40 Ma. Teresa Rivas 27 June 13, 2010 7:18 am Male CSV Maternity and Normal Spontaneous Cristina S. Velasquez, RM
Age of Gestation, Cephalic in Labor Lying-In Clinic Delivery
5.
Noted by:
_____________________________________ _________________________________________________
_________________________________________________ Signature over printed name of Chief Nurse _________________________________________________ Signature over printed name of Dean
Signature over printed name of Chief Nurse Date Signed: ______________________________________ Signature over printed name of Date Signed: ______________________________________
Date Signed: ______________________________________ Degree:__________________________________________ Clinical Coordinator Degree:__________________________________________
Degree:__________________________________________ a.) PRC NO: ______________________________________ Date Signed: ______________________________________ a.) PRC NO: ______________________________________
a.) PRC NO: ______________________________________ Valid Until: Degree:__________________________________________ Valid Until:
Valid Until: _____________________________________ _________________________________________ a.) PRC NO: ______________________________________ _________________________________________
b.) PNA NO: ______________________________________ b.) PNA NO: ______________________________________ Valid Until: _____________________________________ b.) PNA NO: ______________________________________
Valid Until: ____________________________________ Valid Until: ____________________________________ b.) PNA NO: ______________________________________ Valid Until: ____________________________________
Valid Until: ____________________________________ c.) ADPCN NO:____________________________________
Valid Until: _____________________________________
Manila

IV. Deliveries Assisted
Name of Date of Time of Gender of Supervised by: Signature of

No. Case No. Diagnosis Age Name of Hospital Type of Delivery
Mother Delivery Delivery Baby Qualified C.I.
Pregnancy Uterine 38-39 weeks Age of Lovely August 12, Male Zamora Medical Clinic and
1. I008-1921 22 9:26 am Normal Spontaneous Delivery Amelia M. Sta. Maria, RN, PhD
Gestation, Cephalic in Labor Casinas 2009 Lying- In
10-0367 Gravida 2 Parity 2 (2002)Pregnancy Gemma 19 February 8, 7:40 pm Male Taguig Pateros District Normal Spontaneous Delivery Lita Bacudio, RN, MAN
2. Uterine Full Term 36-37 weeks Age of Bautista 2010 Hospital
Gestation, Cephalic in Labor
10-0458 Gravida 2 Parity 2 (2002)Pregnancy Benjie Beth 24 February 22, 2:43 pm Male Taguig Pateros District Normal Spontaneous Delivery Lita Bacudio, RN, MAN
3. Uterine 38-39 weeks Age of Gestation, Sangdaan 2010 Hospital
Cephalic in Labor
105-00 Gravida 3 Parity 2 Pregnancy Uterine 39 Buena Rose 25 June 12, 7:10 am Male CSV Maternity and Lying- Normal Spontaneous Delivery Evangeline Rabaino RN, MAN
4. weeks Age of Gestation, Cephalic in Barasi 2010 In Clinic
Labor
107-10 Gravida 2 Parity 1 Pregnancy Uterine Rosalyn 24 June 13, 11:04 am Male CSV Maternity and Lying- Normal Spontaneous Delivery Evangeline Rabaino RN, MAN
5. 37-38 weeks Age of Gestation, Cephalic Abawag 2010 In Clinic
in Labor
Noted by: _________________________________________________

Valid Until: _____________________________________
Manila

V. Cord Dressing
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital Supervised by: Signature of Qualified C.I.
Male Zamora Medical Clinic and

1. I008-1930 August 13, 2009 Baby Boy Gumap-os Mariarina Gumap-os 38 Amelia M. Sta. Maria, RN, PhD
Lying- In
10-0364 February 8, 2010 Baby Girl dela Cruz Female Annabelle dela Cruz 35 Taguig Pateros District Lita Bacudio, RN, MAN
Hospital
2.
10-0374 February 9, 2010 Baby Boy Ronquillo Male Jessica Ronquillo 20 Taguig Pateros District Lita Bacudio, RN, MAN
Hospital
3.
10-0466 February 23, Baby Girl Gregorio Female Alma Gregorio 27 Taguig Pateros District Lita Bacudio, RN, MAN
2010 Hospital
4.
104-94 June 11, 2010 Baby Boy Tanag Male Nina Tanag 33 CSV Maternity and Lying-In Evangeline Rabaino RN, MAN
Clinic
5.
Noted by: _________________________________________________

Valid Until: _____________________________________

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REPUBLIC OF THE PHILIPPINES

PROFESSIONAL REGULATION COMMISSION

Name of Student: Flor Anne D. de Jesus_______________________________________________________________________________________________________________________________

Craniotomy Jose Reyes

Noted by: _________________________________________________

Name of Student: Monique Isah S. de Belen______________________________________________________________________________________________________________________________

II. Minor Operations

December 22, Emergency Benedicto Josef, Irene Latosa,

Noted by: _ _____________ Signature over printed name of Dean

Name of Student: Monique Isah S. de Belen______________________________________________________________________________________________________________________________

III. Actual Deliveries

Name of Student: Monique Isah S. de Belen______________________________________________________________________________________________________________________________

IV. Deliveries Assisted

Name of Date of Time of Gender of Supervised by: Signature of

Noted by: _________________________________________________

Name of Student: Monique Isah S. de Belen______________________________________________________________________________________________________________________________

Male Zamora Medical Clinic and

Noted by: _________________________________________________

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