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CORD DRESS
Case Number:_______________________ Date Delivered:____________________ Time
Delivered:_________________
Name of Baby:_______________________________________________________Gender of
Baby:__________________
Name of
Mother:____________________________________________________________________________________
(First name)
(Middle name)
(Last name)
Weight:_______________________________
Length:________________________________________
Head Circumference:______________ Chest Circumference:______________ Abdominal
Circumference:_____________
Temperature:___________________________ Type of
Delivery:______________________________________________
Pediatrician on Duty:_________________________________ Obstetrician on
duty:______________________________
Nurse on Duty:______________________________________ Midwife on
duty:_________________________________
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________
_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________
Signature
OR Nurse
PRC License
CORD DRESS
Case Number:_______________________ Date Delivered:____________________ Time
Delivered:_________________
Name of Baby:_______________________________________________________Gender of
Baby:__________________
Name of
Mother:____________________________________________________________________________________
(First name)
(Middle name)
(Last name)
Weight:_______________________________
Length:________________________________________
Head Circumference:______________ Chest Circumference:______________ Abdominal
Circumference:_____________
Temperature:___________________________ Type of
Delivery:______________________________________________
Pediatrician on Duty:_________________________________ Obstetrician on
duty:______________________________
Nurse on Duty:______________________________________ Midwife on
duty:_________________________________
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________
___________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
Signature
OR Nurse
PRC License
HANDLE
Case Number:________________________
Patients name:_______________________________________________________________________
Age:__________
(First name)
(Middle name)
Gravida:_________________
Living:_________________
Para:________________
Date of Delivery:___________________
Newborn:___________
Time
of
(Last name)
Abortion:____________________
Delivery:_______________________
Gender
of
Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Obstetrician
on
Duty:
by:_________________________________
_____________________________________
Nurse
on
duty:____________________________________________
duty:____________________________
Handled
Midwife
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________
_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
Signature
OR Nurse
PRC License
on
COTABATO CITY
HANDLE
Case Number:________________________
Patients
Age:__________
name:_______________________________________________________________________
(First name)
(Middle name)
Gravida:_________________
Living:_________________
Para:__________________
Date of Delivery:___________________
Newborn:_____________
Time
of
(Last name)
Abortion:_________________
Delivery:__________________
Gender
of
Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Obstetrician
on
Duty:
by:______________________________
____________________________________
Nurse
on
duty:_______________________________________
duty:____________________________
Handled
Midwife
on
Handled
(student):________________________________________________________________________________
by
Assisted
(student):________________________________________________________________________________
by
Cord
Dressed
(student):____________________________________________________________________________
by
Name
Institution:_________________________________________________________________________________
of
___________________________________
_________________________________
Signature over Printed Name
over Printed Name
Signature
Clinical Instructor
OR Nurse
PRC License
ASSIST
Case Number:________________________
Patients name:_______________________________________________________________________
Age:__________
(First name)
(Middle name)
Gravida:_________________
Living:____________________
Para:________________
Date of Delivery:___________________
Newborn:_____________
Time
of
(Last name)
Abortion:_________________
Delivery:__________________
Gender
of
Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Obstetrician
on
Duty:
by:________________________________
__________________________________
Nurse
on
duty:_______________________________________
duty:____________________________
Handled
Midwife
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________
_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Signature
Clinical Instructor
OR Nurse
PRC License
on
ASSIST
Case Number:________________________
Patients
Age:__________
name:_______________________________________________________________________
(First name)
Gravida:_________________
Living:_________________
(Middle name)
Para:________________
Date of Delivery:___________________
Newborn:_____________
Time
of
(Last name)
Abortion:___________________
Delivery:__________________
Gender
of
Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Obstetrician
on
Duty:
by:________________________________
__________________________________
Nurse
on
duty:_______________________________________
duty:____________________________
Handled
Midwife
on
Handled
(student):________________________________________________________________________________
by
Assisted
(student):________________________________________________________________________________
by
Cord
Dressed
(student):____________________________________________________________________________
by
Name
Institution:_________________________________________________________________________________
of
____________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________
Signature
OR Nurse
PRC License
MINOR
Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________
Operation
Patients name:__________________________________________________________________Sex:______
Age:______
(First name)
(Middle name)
(Last name)
Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_
_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________
Signature
OR Nurse
PRC License
MINOR
Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________
Operation
Patients name:__________________________________________________________________Sex:______
Age:______
(First name)
(Middle name)
(Last name)
Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_
________________________________
______________________________
__
Signature
Clinical Instructor
OR Nurse
PRC License
MAJOR
Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________
Operation
Patients name:__________________________________________________________________Sex:______
Age:______
(First name)
(Middle name)
(Last name)
Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_
_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Signature
Clinical Instructor
OR Nurse
PRC License
MAJOR
Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________
Operation
Patients name:__________________________________________________________________Sex:______
Age:______
(First name)
(Middle name)
(Last name)
Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_
Name of
Institution:__________________________________________________________________________________
________________________________
______________________________
__
Signature
Clinical Instructor
PRC License No._____________
No._____________
OR Nurse
PRC License