ACTUAL DELIVERY in Pasay City General Hospital, Pasay City HANDLED CASES Prepared by:

CAASI, Angelito Liday

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)

D.R. FORM ACTUAL DELIVERY FORM

SUPERVISED BY: Clinical Instructor Name and Signature

CLINICAL COORDINATOR

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until ADPCN NO.: Valid Until

DEAN

ACTUAL DELIVERY in Pasay City General Hospital, Pasay City ASSISTED CASES Prepared by:
CAASI, Angelito Liday
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)

D.R. FORM ACTUAL DELIVERY FORM

SUPERVISED BY: Clinical Instructor Name and Signature

CLINICAL COORDINATOR

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until ADPCN NO.: Valid Until

DEAN

IMMEDIATE NEWBORN CORD CARE In Pasay City General Hospital, Pasay City Prepared by:
CAASI, Angelito Liday
Date Performed and Time Started Patients INITIAL Only CASE Number (not applicable for birthing/ Lying- in Clinics/ Homes) IMMEDIATE NEWBORN CARE PERFORMED Indicate where performed e.g. D.R, Nursery, NICU, or Home D.R Nurse on Duty Name and Signature (If midwife on Duty, Signature Not Required) SUPERVISED BY: Clinical Instructor Name and Signature

ICNB Form IMMEDIATE CARE OF THE NEWBORNFORM

CLINICAL COORDINATOR

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until ADPCN NO.: Valid Until

DEAN

SURGICAL SCRUB in Pasay City General Hospital, Pasay City Prepared by:
CAASI, Angelito Liday
Date Performed and Time Started Patients INITIAL Only CASE Number SURGICAL PROCEDURE PERFORMED O.R Nurse on Duty Name and Signature

OR Form 1A O.R. SCRUB FORM Major

SUPERVISED BY: Clinical Instructor Name and Signature

Rowena Verzosa, RN, MSN

Rowena Verzosa, RN, MSN

Rowena Verzosa, RN, MSN

CLINICAL COORDINATOR

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until ADPCN NO.: Valid Until

DEAN

MINOR CASES in Pasay City General Hospital, Pasay City Prepared by:
CAASI, Angelito Liday
Date Performed and Time Started Patients INITIAL Only CASE Number SURGICAL PROCEDURE PERFORMED O.R Nurse on Duty Name and Signature

OR Form 1A O.R. Minor cases

SUPERVISED BY: Clinical Instructor Name and Signature

Rowena Verzosa, RN, MSN

Rowena Verzosa, RN, MSN

Rowena Verzosa, RN, MSN

CLINICAL COORDINATOR

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until ADPCN NO.: Valid Until

DEAN

SURGICAL CIRCULATING in Pasay City General Hospital, Pasay City Prepared by:
CAASI, Angelito Liday
Date Performed and Time Started Patients INITIAL Only CASE Number SURGICAL PROCEDURE PERFORMED O.R Nurse on Duty Name and Signature

OR Form 1A O.R. CIRCULATING FORM Major

SUPERVISED BY: Clinical Instructor Name and Signature

Rowena Verzosa, RN, MSN

Rowena Verzosa, RN, MSN

Rowena Verzosa, RN, MSN

CLINICAL COORDINATOR

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until

Signature Over Printed Name Date Signed: Degree: PRC No.: Valid Until PNA No.: Valid Until ADPCN NO.: Valid Until

DEAN