CORD CARE FORM

ODC Form 1c

JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu www.jru.edu.ph

IMMEDIATE NEWBORN CORD CARE in _____ Prepared by: CORA LE O. VITERBO Printed Name with Signature of Student :

San Juan Medical Center, San Juan City__________________ H ospital, Municipality/City/Province

CORA LE O. VITERBO______________ ___________

Date Performed and Time Started

Patients INITIALS (only)

Case Number (not applicable for Birthing/Lyin

Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or

Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

July 19, 2011 1:04 p.m.

Baby boy A. #13525

Neonatal Intensive Care Unit

Jesucristina Picardal R.N.

Racquel V. Magsipoc R.N., M.A.N.

Noted by: ___________LOTIS MELINDA V. BERNARTE R.N. MAN______________ ACEBEDO R.N. MAN_______________
(Print Name and Signature) Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________ Date document is signed: _______________ Time: ______________________ __ Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___

Approved by:

WENDY R.
(Print Name and

Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014 Date document is signed: __________ Time: _______________________________ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing _______________________

_______

ACTUAL DELIVERY FORM

ODC Form 1A

(STRICTLY NO JOSE RIZAL UNIVERSITY DELEGATES) 80 Shaw Boulevard, Mandaluyong City

Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu www.jru.edu.ph

ACTUAL DELIVERY in

______________Mandaluyong City Medical Center, Mandaluyong City_________________________ Hospital, Municipality/City/Province

CORA LE O. VITERBO______________ ___________

Prepared by: CORA LE O. VITERBO Printed Name with Signature of Student :

Date Performed and Time Started

Patients INITIALS (only)

Case Number (not applicable for Birthing/Lyin

PROCEDURE PERFORMED Normal Spontaneous Delivery Normal Spontaneous Delivery

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

April 28, 2011 6:28 p.m. April 28, 2011 8:42 p.m.

I.Q. 545550 Y.R. 545553

Charmaine Albaa R.N. Charmaine Albaa R.N.

Teresita J. Dimayacyac R.N., M.A.N. Teresita J. Dimayacyac R.N., M.A.N.

Noted by: ___________LOTIS MELINDA V. BERNARTE R.N. MAN______________ R.N. MAN_______________

(Print Name and Signature) Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________ ______________ Date document is signed: _______________ Time: ______________________ __ Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___

Approved by:

WENDY R. ACEBEDO
(Print Name and

Dean, PRC I.D. No. 0191572

Valid Until June 11, 2014

Date document is signed: __________ Time: _______________________________ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing _______________________

(STRICTLY NO DELEGATES) JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City

ASSISTED DELIVERY FORM

ODC Form 1B

Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu www.jru.edu.ph

ACTUAL DELIVERY in

______________Mandaluyong City Medical Center, Mandaluyong City_________________________ Hospital, Municipality/City/Province

CORA LE O. VITERBO ___________ D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)

Prepared by: COR A LE O. VITERBO Printed Name with Signature of Student :

Date Performed and Time Started January 21, 2012 4:41 p.m. January 22, 2012 2:35 p.m. January 24, 2012 10: 43 a.m. January 24, 2012 11:10 a.m. January 24, 2012 3:04 p.m.

Patients INITIALS (only)

Case Number (not applicable for Birthing/Lyin

PROCEDURE PERFORMED Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

SUPERVISED BY Clinical Instructor Name and Signature

R.O. 552786 N.B. 552807 F.V. 552842 I.L. 552848 M.D. 552851

Charmaine Albaa R.N. Charmaine Albaa R.N. Charmaine Albaa R.N. Charmaine Albaa R.N. Charmaine Albaa R.N.

Teresita J. Dimayacyac R.N., M.A.N. Teresita J. Dimayacyac R.N., M.A.N. Teresita J. Dimayacyac R.N., M.A.N. Teresita J. Dimayacyac R.N., M.A.N. Teresita J. Dimayacyac R.N., M.A.N.

Noted by: ___________LOTIS MELINDA V. BERNARTE R.N. MAN______________ R.N. MAN_______________

(Print Name and Signature) Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________ ______________ Date document is signed: _______________ Time: ______________________ __

Approved by:

WENDY R. ACEBEDO
(Print Name and

Dean, PRC I.D. No. 0191572 Date document is signed: __________ Time:

Valid Until June 11, 2014 _______________________________

Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________

___

Specify Highest Nursing Degree Earned: Masters of Arts in Nursing

_______________________

CORD CARE FORM

ODC Form 1C

(STRICTLY NO DELEGATES) JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu www.jru.edu.ph

IMMEDIATE NEWBORN CORD CARE in Prepared by: CORA LE O. VITERBO Printed Name with Signature of Student :

__ Mandaluyong City Medical Center, Mandaluyong City_______ H ospital, Municipality/City/Province

CORA LE O. VITERBO ___________ Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)

Date Performed and Time Started

Patients INITIALS (only)

Case Number (not applicable for Birthing/Lyin

SUPERVISED BY Clinical Instructor Name and Signature

January 23, 2012 7:55 p.m.

Baby Boy A. 552863

Neonatal Intensive Care Unit

Thelma Bendian R.N.

Menchie T. Hilay R.N., M.A.N.

Noted by: ___________LOTIS MELINDA V. BERNARTE R.N. MAN______________ R.N. MAN_______________

(Print Name and Signature) Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________ ______________ Date document is signed: _______________ Time: ______________________ __ Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___

Approved by:

WENDY R. ACEBEDO
(Print Name and

Dean, PRC I.D. No. 0191572

Valid Until June 11, 2014

Date document is signed: __________ Time: _______________________________ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing _______________________

(STRICTLY NO DELEGATES)

ODC Form 2B O.R MINOR FORM JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu www.jru.edu.ph SURGICAL SCRUB in

_____________Mandaluyong City Medical Center, Mandaluyong City________________________ Hospital, Municipality/City/Province

CORA LE O. VITERBO ___________

Prepared by: CORA LE O. VITERBO Printed Name with Signature of Student :

Date Performed and Time Started July 5, 2011 12:30 a.m. July 4, 2011 11:45 p.m.

Patients INITIALS (only) Case Number

SURGICAL PROCEDURE PERFORM Suturing Suturing

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

SUPERVISED BY Clinical Instructor Name and Signature Gabriela E. Castillon R.N., M.A.N. Gabriela E. Castillon R.N., M.A.N.

M.C. 022789 60770 E.T. 092977

Jefferson Flor R.N. Jefferson Flor R.N.

Noted by: ___________LOTIS MELINDA V. BERNARTE R.N. MAN______________ ACEBEDO R.N. MAN_______________
(Print Name and Signature) Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________ Date document is signed: _______________ Time: ______________________ __ Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___

Approved by:

WENDY R.
(Print Name and

Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014 Date document is signed: __________ Time: _______________________________ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing _______________________

_______

(STRICTLY NO DELEGATES) JOSE RIZAL UNIVERSITY

80 Shaw Boulevard, Mandaluyong City Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu

ODC Form 2B O.R MINOR FORM

www.jru.edu.ph SURGICAL SCRUB in

______________Navotas Emergency and Lying-In Clinic, Navotas City_________________________ Hospital, Municipality/City/Province

CORA LE O. VITERBO ___________

Prepared by: CORA LE O. VITERBO Printed Name with Signature of Student :

Date Performed and Time Started June 25, 2011 9:15 a.m.

Patients INITIALS (only) Case Number

SURGICAL PROCEDURE PERFORM Onchiectomy

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

SUPERVISED BY Clinical Instructor Name and Signature

R.C. 2011-1542

Arlenedale A. Canto R.N., M.A.N.

Eleonor C. Tangkeko R.N., M.A.N.

Noted by: ___________LOTIS MELINDA V. BERNARTE R.N. MAN______________ ACEBEDO R.N. MAN_______________
(Print Name and Signature) Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________ Date document is signed: _______________ Time: ______________________ __ Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___

Approved by:

WENDY R.
(Print Name and

Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014 Date document is signed: __________ Time: _______________________________ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing _______________________

_______

(STRICTLY NO DELEGATES)