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University Of St.

La Salle College of Nursing


La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
SURGICAL SCRUB in ______________________________________________________________________ Hospital, Municipality/City/Province
Prepared by:

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

(Printed Name and Signature of Student)

Date Performed and Time Started 05-19-11 6:22 AM

Patient's INITIALS (ONLY) Case Number SURGICAL PROCEDURE PERFORMED OR Nurse On Duty (Name and Signature)

Supervised By (Clinical Instructor) Name and Signature Myrvi P. Vergara, RN, MN

M.L.

02031608

Appendectomy Cystoscopy with retrograde pyelography; Transurethral resection of bladder tumor Debridement; Open reduction; Internal fixation; Intramedullary pinning, ulna, left

05-19-11

8:44 AM

R.E.

02020456

Myrvi P. Vergara, RN, MN

10-28-11

12:28 PM

R.M.

02072347

Hermie G. Siroy, RN, MN

Noted by:

Mary Beth P. Diva, RN, MN


Clinical Coordinator

Approved by:

Josephine L. de la Serna, RN, MN


Dean

PRC ID No.: Date document is signed:

0214975

Valid Until: Time:

07-23-12

PRC ID No.:

0037515

Valid Until: Time:

06-03-14
Master in Nursing

Date document is signed: Highest Nursing Degree Earned:

Highest Nursing Degree Earned:

Master in Nursing

University Of St. La Salle College of Nursing


La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
SURGICAL SCRUB in __________________________________________________________________________ Hospital, Municipality/City/Province
Prepared by:

O.R. Form 1B O.R. CIRCULATING FORM

(Printed Name and Signature of Student)

Date Performed and Time Started

Patient's INITIALS (ONLY) SURGICAL PROCEDURE PERFORMED Case Number Cholecystectomy; Common Bile Duct Exploration; T-tube; Intaoperative Cholangiogram; Excision of choledochal cyst; Hepaticojejunostomy; Jejunostomy; Roux-eny; Jackson Pratt Drain
Cesarean section, primary, low transverse cut

OR Nurse On Duty (Name and Signature)

Supervised By (Clinical Instructor) Name and Signature

05-19-11

12:06 PM

A.G.

02028514

Myrvi P. Vergara, RN, MN

08-04-11

11:00 AM

C.C.L.

02050484

Myrvi P. Vergara, RN, MN

10-28-11

8:52 AM

J.C.

02069383

Open reduction; Internal fixation; Intramedullary nailing, tibia, right

Hermie G. Siroy, RN, MN

Noted by: PRC ID No.: Date document is signed: Highest Nursing Degree Earned:

Mary Beth P. Diva, RN, MN


Clinical Coordinator

Approved by:

Josephine L. de la Serna, RN, MN


Dean

0214975

Valid Until: Time:

07-23-12

PRC ID No.:

0037515

Valid Until: Time:

06-03-14
Master in Nursing

Date document is signed: Highest Nursing Degree Earned:

Master in Nursing

University Of St. La Salle College of Nursing


La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
ACTUAL DELIVERY in __________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:

D. R. Form ACTUAL DELIVERY FORM

(Printed Name and Signature of Student)

Bliss Vinco Caraig

Date Performed and Time Started 08-06-11 3:41 PM

Patient's INITIAL (only) PROCEDURE PERFORMED Case Number

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

Supervised By (Clinical Instructor) Name and Signature Myrvi P. Vergara, RN, MN

S.M.T.

11-3205

Normal Spontaneous Vaginal Delivery

09-09-11

4:45 PM

G.A.

11-5054

Normal Spontaneous Vaginal Delivery

Arnella V. Bancaya, RN, MN

Noted by: PRC ID No.: Date document is signed: Highest Nursing Degree Earned:

Mary Beth P. Diva, RN, MN


Clinical Coordinator

Approved by:

Josephine L. de la Serna, RN, MN


Dean

0214975

Valid Until: Time:

07-23-12

PRC ID No.:

0037515

Valid Until: Time:

06-03-14

Date document is signed: Highest Nursing Degree Earned:

Master in Nursing

Master in Nursing

University Of St. La Salle College of Nursing


La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
ACTUAL DELIVERY in Pontevedra Rural Health Unit, Pontevedra, Negros Occidental Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:

D. R. Form ACTUAL DELIVERY FORM

(Printed Name and Signature of Student)

BLISS V. CARAIG

Date Performed and Time Started 05-25-11 7:27 AM

Patient's INITIAL (only) PROCEDURE PERFORMED Case Number

DR Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) Ana Jurada, RM

Supervised By (Clinical Instructor) Name and Signature


Gardenia T. de los Santos, RN, MN

E.M.

2011-323

Normal Spontaneous Vaginal Delivery

Noted by: PRC ID No.: Date document is signed: Highest Nursing Degree Earned:

Mary Beth P. Diva, RN, MN


Clinical Coordinator

Approved by:

Josephine L. de la Serna, RN, MN


Dean

0214975

Valid Until: Time:

07-23-12

PRC ID No.:

0037515

Valid Until: Time:

06-03-14

Date document is signed: Highest Nursing Degree Earned:

Master in Nursing

Master in Nursing

University Of St. La Salle College of Nursing


La Salle Avenue, Bacolod City 6100 Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing_usls@yahoo.com.ph / www.usls.edu.ph
IMMEDIATE NEWBORN CORD CARE in Teresita Lopez Jalandoni Provincial Hospital, Silay City, Negros Occidental Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:

ICNB Form IMMEDIATE CARE OF THE NEWBORN FORM

(Printed Name and Signature of Student)

BLISS V. CARAIG

Date Performed and Time Started 08-03-11 8:29 AM

Patient's INITIAL (only) Case Number

Immediate Newborn Cord Care PERFORMED


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

DR/Nursery Nurse On Duty


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

Supervised By (Clinical Instructor) Name and Signature Arnella V. Bancaya RN, MN

G.L.

11-3144

Delivery Room

Cecilia Tabat, RM

08-03-11

3:22 PM

G.A.

11-3157

Delivery Room

Neila Rose Parreas, RM

Arnella V. Bancaya RN, MN

09-09-11

11:57 AM

B.R.

11-5047

Delivery Room

Cecilia Tabat, RM

Kristel Marie D. Artagame RN, MN

Noted by:

Mary Beth P. Diva, RN, MN


Clinical Coordinator

Approved by:

Josephine L. de la Serna, RN, MN


Dean

PRC ID No.: Date document is signed:

0214975

Valid Until: Time:

07-23-12

PRC ID No.:

0037515

Valid Until: Time:

06-03-14

Date document is signed: Highest Nursing Degree Earned:

Highest Nursing Degree Earned:

Master in Nursing

Master in Nursing