WORLD CITI COLLEGES

960 Aurora Blvd., Cubao Quezon City Tel. # 9138380 Fax # 9138380 Local 421

E-mail Address: info@worldciti.educ.ph Web-Site www.worldciti.edu.ph

ACTUAL DELIVERY in WORLD CITI MEDICAL CENTER, QUEZON CITY Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Print Name and Signature of Student ROSE ANN R. GUTIERREZ
D.R. Form ACTUAL DELIVERT FORM

Date Performed and Time Started

Patients INITIAL Only Case Number

(not applicable for Birthing/Lying-in Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse on Duty (Name and Signature) (If Midwife on Duty, signature not required

SUPERVISED BY Clinical Instructor Name and Signature

NOVEMBER 29,2011 12:25PM DECEMBER 09,2011 04:20AM JANUARY 08,2012 12:16AM

S.B. 183682 W.F. 74016 J.M. 78210

NORMAL SPONTANEOUS DELIVERY RIA GLEIZA RAMIREZ, RN NORMAL SPONTANEOUS DELIVERY RIA GLEIZA RAMIREZ, RN NORMAL SPONTANEOUS DELIVERY MARICRIS, BACSAL, RN JENNY R. SAN JUAN, RN,MAN JENNY R. SAN JUAN, RN,MAN JENNY R. SAN JUAN, RN,MAN

IMMEDIATE NEWBORN CORD CARE in WORLD CITI MEDICAL CENTER, QUEZON CITY Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Print Name and Signature of Student Date Performed and Time Started ICNB Form ROSE ANN R. GUTIERREZ
IMMEDIATE CARE OF THE NEWBORN FORM

Patients INITIAL Only Case Number

(not applicable for Birthing/Lying-in Clinics/Homes)

Immediate Newborn Cord Care PERFORMED

Indicate where performed e.g. D.R.., Nursery, NICU, or Home

Nurse on Duty (Name and Signature) (If Midwife on Duty, signature not required)

SUPERVISED BY Clinical Instructor Name and Signature

DECEMBER 8,2011 02:50PM DECEMBER 10,2011 08:35AM JANUARY 15,2012

09:52AM

BABY BOY M. 80346 BABY GIRL R. 80399 BABY GIRL P. 81689

DELIVERY ROOM SHERY ANN CRUZ, RN OPERATING ROOM MARY GRACE ASANUDDIN, RN DELIVERY ROOM JOANNE BARRETO, RN JENNY R. SAN JUAN, RN,MAN JENNY R. SAN JUAN, RN,MAN JENNY R. SAN JUAN, RN,MAN

(STRICTLY NO DESIGNATES) (These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)

WORLD CITI COLLEGES

960 Aurora Blvd., Cubao Quezon City Tel. # 9138380 Fax # 9138380 Local 421

E-mail Address: info@worldciti.educ.ph Web-Site www.worldciti.edu.ph

SURGICAL SCRUB in _______________________________________________________________ Hospital, Municipality/City/Province Prepared by: Print Name and Signature of Student_______________________________________________________________

O.R. Form 1A
O.R. SCRUB FORM Major

Date Performed and Time Started

Patients INITIALS Only Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

CIRCULATING in __________________________________________________________
Hospital, Municipality/City/Province Prepared by: Print Name and Signature of Student______________________________________________________________ Date Performed and Time Started Patients INITIALS Only Case Number O.R. Form 1B
O.R. CIRCULATING FORM

SURGICAL PROCEDURE PERFORMED

Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

(STRICTLY NO DESIGNATES) (These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)