PWU PRC Forms Templates

Name of Student: FERDINAND N.
ESTRADA ____ _______________________________

Name and Address of School: The Philippine Women’s University, Taft Avenue Manila ____________________
Accreditation Level (if any): Level II PAASCU Re-accredited Year granted: November 23, 2007 ____________________
Date School/Program was recognized: July 19, 1968 Number: S-289 Year: 1968 ____________
First Course (if any): none _______________ School Graduated From: Not Applicable Year: Not Applicable ____________________________
Year of admission in the Bachelor of Science in Nursing Program: June 2005 ____________________
Year of Graduation (BSN Program): December 20, 2008__ ___ ____________
I. Major Operations
Date Name of Signature of
Case Operation Type of Name of
No. Of Name of Patient Diagnosis Name of Surgeon O.R. Scrub O.R Scrub
No. Performed Anesthesia Hospital
Operation Nurse Nurse
PO3 Julius P. Ualat RN,
May 12, Roldan Galingana General Beethoven D. Mendoza, Philippine National
1. 024518 Staghorn Calculus Left Nephrolitothomy Left PRC License No.
2008 Peralta Anesthesia MD Police General
0329161
Hospital
Excision of Fibrosis, Anterior
Capsulatomy, Partial SPO1 Teodolito D.
Philippine National
May 13, Emilda Cadiz Soft Tissue Contracture Left Aponeurosis, Release of Axillary Block Cabasal RN,
2. 024549 Gerardo M. Sison, MD Police General
2008 Torrevillas Elbow Brachial, Manual Anesthesia PRC License No.
Hospital
Manipulation, Extension 0464311
Flexion Left Elbow
Manual Small Incision
Cataract, Surgery Rig Rizal Medical Cariel V. Ronquillo, RN
November Senile Mature Cataract Right Local
3. 787954 Omar Abdullah Temporal Area Incision and San Buenaventura, MD Center PRC License No.
14, 2008 Eye Anesthesia
Poterior Chamber Intra 0367290
Ocular Lens
Gravida Three (3) Parity Two
(2) Low Segment Cesarean Subarachnoid Rizal Medical Cariel V. Ronquillo, RN
November Nora San Jose
4. 799977 (2002) Pregnancy Uterine Section two times and Block Dolores C. Cunanan, MD Center PRC License No.
16, 2008 Mangalimam
41 5/7 Weeks by Last Bilateral Tubal Ligation Anesthesia 0367290
Menstrual Period
Acute Abdominal Hematoma Exploratory Laparotomy +
zone three secondary to Retroperipheral Exploration +
Wound Exploration Left Thigh + Delrine Rose M. De
December Landinez Multiple Gun Shot Wound Endotracheal Rizal Medical
5. 857923 End to End Anastomosis Left Geobert Uyquiengco, MD Jesus RN, PRC License
15, 2008 Geronimo common Femoral Anatomy common Femoral Artery + Repair Anesthesia Center
No. 0299104
injury secondary to Multiple Femoral vein + Jackson-Pratts+
Gun Shot Wound Fasciotomy + Debridement
Prepared by: Noted by: Concurred by: Approved by:

_______________ ____________________ __________________________ ________________________________ ___________________________ ___ ___________________________
ESTRADA, FERDINAND N. MYRNA S. RIVERA PSUPT. NORMITA O. CO LOUISE MARIE D. FLORES MARIETTA C. RAMOS-FABROS
Student Nurse Clinical Coordinator, PWU Chief Nurse of Philippine National Police General Hospital Chief Nurse of Rizal Medical Center Dean, College of Nursing PWU
Date Signed: ____________ Date Signed: __________________ Date Signed: _____________ ____ Date Signed: _________________
Degree: RN, MAN _______ Degree: _ RN, MAN_____________ Degree: RN, MAN, DPA________ Degree: __RN, MAN____________
a) PRC No.: 70309 ________ a) PRC No.: 0109984____________ a.)PRC No.: 0086759___________ a) PRC No: _0038197__________
Valid until: March 28, 2009__ Valid until: August 11, 2009_______ Valid until: March 18, 2012_______ Valid until: ___May 9, 2010____
b) PNA No.: 16969 _______ b) PNA No.: 0109984____________ b.) PNA No.: 103350___________ b) PNA No.: ___77897__________
Valid until: Lifetime ________ Valid until: Lifetime ______________ Valid until: Lifetime ___________ Valid until: __Lifetime_________
c.)ANSAP No.:015334___________ c.)ANSAP No.:00192__________ c) ADPCN No.: __0646__________
Valid until: July 24, 2009 ____ Valid until: Lifetime ___________ Valid until: December 2009_____
Name of Student: FERDINAND N. ESTRADA ____ _________________________________
Name and Address of School: The Philippine Women’s University, Taft Avenue Manila _____ ______________
Accreditation Level (if any): Level II PAASCU Re-accredited Year granted: November 23, 2007 ______________________
Date School/Program was recognized: July 19, 1968 Number: S-289 Year: 1968 ______________
First Course (if any): None ____ School Graduated From: Not Applicable Year: Not applicable ______________________________________
Year of admission in the Bachelor of Science in Nursing Program: June 2005 ______________
Year of Graduation (BSN Program): December 20, 2008
______________
II. Minor Operations
Date Name of Signature of
Case Operation Type of Name of
No. Of Name of Patient Diagnosis Name of Surgeon O.R. Scrub O.R Scrub
No. Performed Anesthesia Hospital
Operation Nurse Nurse
Philippine
PSUPT. Celeste F.
Local National Police
1. May 7, 2008 029889 Dwight Padut Redundant Prepuce Circumsicion Dr. Luis Jose H. Bautista Rosetis, RN
Anesthesia General
PRC License No. 010031
Hospital
Philippine
PSUPT. Celeste F.
Michael Gabriel S. Local National Police
2. May 7, 2008 029640 Redundant Prepuce Circumsicion Dr. Luis Jose H. Bautista Rosetis, RN
Guiadani Anesthesia General
Hospital
Philippine
PSUPT. Celeste F.
May 14, Incision and Local National Police
3. 030007 Mamerto Bernabe Jr. Abscess Resolve Dr.Ronald S. Reyes Rosetis, RN
2008 Drainage Anesthesia General
Hospital
Philippine
PSUPT. Celeste F.
May 15, Tendon Cyst Local National Police
4. 029745 Minda S. Sarabia Excision Dr. Vivencio R. Fuentes Rosetis, RN
2008 Right Wrist Anesthesia General
Hospital
Philippine
PSUPT. Celeste F.
May 14, Mass, Back for three (3) years Excision of mass, Local National Police
5. 012904 Glenn Adriano Dr. Reimond C. Sales Rosetis, RN
2008 prior to consultation back Anesthesia General
Hospital
Prepared by: Noted by: Concurred by: Approved by:
_______________ ____________________ _______________________ ________________________________ ___________________________

ESTRADA, FERDINAND N. MYRNA S. RIVERA PSUPT. NORMITA O. CO MARIETTA C. RAMOS-FABROS
Student Nurse Clinical Coordinator, PWU Chief Nurse of Philippine National Police General Hospital Dean, College of Nursing PWU
Date Signed: ____________ Date Signed: __________________ Date Signed: _________________
Degree: RN, MAN _______ Degree: _ RN, MAN_____________ Degree: __RN, MAN____________
a) PRC No.: 70309 ________ a) PRC No.: 0109984____________ a) PRC No: _0038197__________
Valid until: March 28, 2009__ Valid until: August 11, 2009_______ Valid until: ___May 9, 2010____
b) PNA No.: 16969 _______ b) PNA No.: 0109984____________ b) PNA No.: ___77897__________
Valid until: Lifetime ________ Valid until: Lifetime ______________ Valid until: __Lifetime_________
c.)ANSAP No.:015334___________ c) ADPCN No.: __0646__________
Valid until: July 24, 2009 ____ Valid until: December 2009_____
Name of Student: FERDINAND N. ESTRADA ____ ______________________________
Name and Address of School: The Philippine Women’s University, Taft Avenue Manila ____________
Accreditation Level (if any): Level II PAASCU Re-accredited Year granted: November 23, 2007 ________________ ____________________________
Date School/Program was recognized: July 19, 1968 Number: S-289 Year: 1968 _ ____________
First Course (if any): none _______________ School Graduated From: Not Applicable Year: Not Applicable ____________________________
Year of admission in the Bachelor of Science in Nursing Program: June 2005 ____________________________
Year of Graduation (BSN Program): December 20, 2008 ____________
III. Actual deliveries

Gender
Case Name of Date of Time of Name of Type of Supervised by: Supervised by:
No. Diagnosis Age of
No. Mother Delivery Delivery Hospital Delivery Name & Signature C.I. Name & Signature DR SUP
Baby
Gravida One (1) Parity Zero (0)
Jose B. Lingad Normal
Pregnancy Uterine 40 1/7 weeks Angeline October Juanita Teresa F. Gorospe
1. 220697 17 3:50 am Boy Memorial General Spontaneous
Age of Gestation by Last Menstrual Chancoco Buan 13, 2008 Gregorio Mendoza III RN, MAN RN, MAN
Hospital Delivery
Period Cephalic in Labor PRC License No. 0368144 PRC License No. 0132564
Pregnancy Uterine 38 4/7 weeks Jocelyn October Juanita Teresa F. Gorospe
2. 221583 26 6:05 am Girl Memorial General Spontaneous
Age of Gestation by Last Menstrual Esguerra Salas 21, 2008 Gregorio Mendoza III RN, MAN RN, MAN
Hospital Delivery
Pregnancy Uterine 39 weeks Age of Lotlot Awas October
3. 212459 20 11:11 pm Girl Memorial General Spontaneous Juanita Teresa F. Gorospe
Gestation by Last Menstrual Period Torrenmecha 21, 2008
Hospital Delivery Gregorio Mendoza III RN, MAN RN, MAN
Cephalic in Labor
PRC License No. 0368144 PRC License No. 0132564
Gravida Two (2) Parity Two (2) Jose B. Lingad Normal

Rosalinda October Juanita Teresa F. Gorospe
4. 221745 (2002) Pregnancy Uterine, Full Term 28 4:05 am Boy Memorial General Spontaneous
Magday Nunag 23, 2008 Gregorio Mendoza III RN, MAN RN, MAN
Premature Rupture of Membrane Hospital Delivery
Gravida One (1) Parity One (1)
Pregnancy Uterine 39 2/7 weeks Cherry Lyn October Juanita Teresa F. Gorospe
5. 219317 19 4:20 am Girl Memorial General Spontaneous
Age of Gestation by Last Menstrual Ticsay San Luis 29, 2008 Gregorio Mendoza III RN, MAN RN, MAN
Hospital Delivery
Prepared by: Noted By: Concurred by: Approved by:
_____________________________ ________________________________ ____________________________

_______________ _____________________
MYRNA S. RIVERA JULITA M. LATOSQUIN MARIETTA C. RAMOS-FABROS
ESTRADA, FERDINAND N.
Clinical Coordinator, PWU Chief Nurse of Jose B. Lingad General Dean, College of Nursing PWU
Student Nurse
Date Signed: __________________ Hospital Date Signed: _________________
Degree: RN, MAN _____________ Date Signed: __________________ Degree: __RN, MAN___________
a) PRC No.: 70309 _____________ Degree: , RN MAN______________ a) PRC No: _0038197__________
Valid until: March 28, 2009_______ a) PRC No.: 041328_____________ Valid until: ___May 9, 2010______
b) PNA No.: 16969 ____________ Valid until: April 2011____________ b) PNA No.: ___77897__________
Valid until: Lifetime ______________ b) PNA No.:7368_______________ Valid until: __Lifetime___________
Valid until: Lifetime__ _____ c) ADPCN No.: __0646_________
Valid until: December 2009______
Name of Student: FERDINAND N. ESTRADA _______ ________________
Name and Address of School: The Philippine Women’s University, Taft Avenue Manila ________________
Accreditation Level (if any): Level II PAASCU Re-accredited Year granted: November 23, 2007 ________________________
Date School/Program was recognized: July 19, 1968 ___ Number: S-289 ___Year: 1968
First Course (if any): none ________________ School Graduated From: Not Applicable _ Year: Not Applicable __________________________
Year of admission in the Bachelor of Science in Nursing Program: June 2005 ________________
Year of Graduation (BSN Program): December 20, 2008 ________________
IV. Deliveries Assisted

Supervised by: Supervised by:
Date of Time of Gender Name of Type of
No. Case No. Diagnosis Name of Mother Age Name and Signature of Name and Signature by
Delivery Delivery of Baby Hospital Delivery
Qualified C.I. D.R. Supervisor
Gravida Eight (8) Parity Seven (7) Jose B. Lingad Normal
Beverly Ingreso Juanita Teresa F. Gorospe
1 220301 Pregnancy Uterine 35 5/7 weeks Age 32 October 6, 2008 10:00 pm Girl Memorial Spontaneou
Alburo Gregorio Mendoza III RN, MAN RN, MAN
of Gestation by Last Menstrual Period General Hospital s Delivery
Pregnancy Uterine 38-39 weeks Age of Juanita Teresa F. Gorospe
2 220344 Cristina Regalla Muli 17 October 8, 2008 3:20 am Boy Memorial Spontaneou
Gestation by Last Menstrual Period Gregorio Mendoza III RN, MAN RN, MAN
General Hospital s Delivery
Cephalic in Labor PRC License No. 0368144 PRC License No. 0132564
Gravida Two (2) Parity Two (2) (2002) Edsy Samson October 22, Juanita Teresa F. Gorospe
3 220523 26 10:05 pm Girl Memorial Spontaneou
Pregnancy Uterine, Full Term Cephalic Tuazon 2008 Gregorio Mendoza III RN, MAN RN, MAN
in Labor PRC License No. 0368144 PRC License No. 0132564
Pregnancy Uterine 39 5/7 weeks Age of Jennifer Sta. Cruz October 25, Juanita Teresa F. Gorospe
4 222101 17 5:25 am Girl Memorial Spontaneou
Gestation by Last Menstrual Period Moreno 2008 Gregorio Mendoza III RN, MAN RN, MAN
Gravida Six (6) Parity Six (6)
Pregnancy Uterine 38-39 weeks Age of October 29, Juanita Teresa F. Gorospe
5 222395 Robilyn Ariola 22 2:05 am Girl Memorial Spontaneou
Gestation by Last Menstrual Period 2008 Gregorio Mendoza III RN, MAN RN, MAN
Prepared By: Noted By: Concurred By: Approved By:
_______________ ____________________ _____________________________ ________________________________ _____________________________

ESTRADA, FERDINAND N. MYRNA S. RIVERA JULITA M. LATOSQUIN MARIETTA C. RAMOS-FABROS
Student Nurse Clinical Coordinator, PWU Chief Nurse of Jose B. Lingad General Dean, College of Nursing PWU
Date Signed: __________________ Hospital Date Signed: __________________
Degree: RN, MAN _____________ Date Signed: __________________ Degree: __RN, MAN_____________
a) PRC No.: 70309 _____________ Degree: , RN MAN______________ a) PRC No: _0038197____________
Valid until: March 28, 2009_______ a) PRC No.: 041328_____________ Valid until: ___May 9, 2010_______
b) PNA No.: 16969 ____________ Valid until: April 2011____________ b) PNA No.: ___77897___________
Valid until: Lifetime ______________ b) PNA No.:7368_______________ Valid until: __Lifetime____________
Valid until: Lifetime__ _____ c) DPCN No.: __0646____________
Valid until: December 2009_______
Name of Student: FERDINAND N. ESTRADA ____ __________________________
Name and Address of School: The Philippine Women’s University, Taft Avenue Manila ________
Accreditation Level (if any): Level II PAASCU Re-accredited Year granted: November 23, 2007 ________________
Date School/Program was recognized: July 19, 1968 Number: S-289 Year: 1968 ________
First Course (if any): none _______________ School Graduated From: Not Applicable Year: Not Applicable ________________________
Year of admission in the Bachelor of Science in Nursing Program: June 2005 ________________
Year of Graduation (BSN Program): December 20, 2008
V. Cord Dressing
Supervised by:
Case Date Gender of Name of
No. Name of Baby Name of Mother Age Name & Signature of Qualified
No. Performed Baby Hospital
C.I.
Jose B. Lingad Memorial General

1. 198779 Feb 7, 2008 Baby Layug Girl Rowella Dimalanta Layug 20
Hospital Gregorio Mendoza III RN, MAN
Jose B. Lingad Memorial General

2. 022265 Feb 20, 2008 Baby Paule Girl Agnes Amurao Paule 31 Gregorio Mendoza III RN, MAN
Hospital
October 21, Jose B. Lingad Memorial General

3. Baby Canlas Girl Alicia David Canlas 28 Gregorio Mendoza III RN, MAN
221578 2008 Hospital

4. 221691 Baby Rosario Girl Pinky Manalo Rosario 24
2008 Hospital Gregorio Mendoza III RN, MAN

5. 069627 Baby Obina Girl Ressie Buscuit Obina 29 Gregorio Mendoza III RN, MAN
2008 Hospital
Prepared By: Noted By: Concurred by: Approved by:
________________________________ ________________________________ ___________________________

_______________ ____________________
MYRNA S. RIVERA JULITA M. LATOSQUIN MARIETTA C. RAMOS-FABROS
ESTRADA, FERDINAND N.
Clinical Coordinator, PWU Chief Nurse of Jose B. Lingad District Dean, College of Nursing PWU
Student Nurse
Date Signed: _________________ Hospital Date Signed: _________________
Degree: RN, MAN ___________ Date Signed: __________________ Degree: __RN, MAN____________
a) PRC No.: 70309 ____________ Degree: , RN MAN______________ a) PRC No: _0038197__________
Valid until: March 28, 2009__ a) PRC No.: 041328_____________ Valid until: ___May 9, 2010____
b) PNA No.: 16969 ___________ Valid until: April 2011____________ b) PNA No.: ___77897__________
Valid until: Lifetime ________ ___ b) PNA No.:7368_______________ Valid until: __Lifetime_________
Valid until: Lifetime___ _____ c) ADPCN No.: __0646__________
Valid until: December 2009_____

PWU PRC Forms Templates

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Name of Student: FERDINAND N.

ESTRADA ___________________________

Prepared by: Noted by: Concurred by: Approved by:

Prepared by: Noted by: Concurred by: Approved by:

___ _ _____

III. Actual deliveries

Gravida Two (2) Parity Two (2) Jose B. Lingad Normal

_

IV. Deliveries Assisted

Prepared By: Noted By: Concurred By: Approved By:

_ _ ___________

Jose B. Lingad Memorial General

Jose B. Lingad Memorial General

October 21, Jose B. Lingad Memorial General

October 22, Jose B. Lingad Memorial General

October 28, Jose B. Lingad Memorial General

Prepared By: Noted By: Concurred by: Approved by:

______ _

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