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UNIVERSITY OF PANGASINAN Name of Patient: _______________________________________________ Name of Patient: _______________________________________________

COLLEGE OF NURSING Address:______________________________________________________ Address:______________________________________________________


DAGUPAN CITY Age: _________________Sex:____________Ward____________________ Age: _________________Sex:____________Ward____________________
Case No.: _______________________Date: _________________________ Case No.: _______________________Date: _________________________
MAJOR CASE SLIP Pre-op Diagnosis:_______________________________________________ Pre-op Diagnosis:_______________________________________________
_____________________________________________________________ _____________________________________________________________
NAME OF STUDENT: Post-op Diagnosis:______________________________________________ Post-op Diagnosis:______________________________________________
_____________________________________________________________ _____________________________________________________________
STUDENT NUMBER: Operation Performed: ___________________________________________ Operation Performed: ___________________________________________
_____________________________________________________________ _____________________________________________________________
Time Started:_________________ Time Finished_____________________ Time Started:_________________ Time Finished_____________________
Surgeon: _____________________________________________________ Surgeon: _____________________________________________________
ZENAIDA M. BAUTISTA RN, MAN Assistant:_____________________________________________________ Assistant:_____________________________________________________
CLINICAL COORDINATOR Anesthesiologist:_______________________________________________ Anesthesiologist:_______________________________________________
Type of Anesthesia: ____________________________________________ Type of Anesthesia: ____________________________________________
PRC NO.: 0133422 VALID UNTIL: July 27, 2011 Anesthesia Started: _____________________________________________ Anesthesia Started: _____________________________________________
Instrument Nurse: ______________________________________________ Instrument Nurse: ______________________________________________
PNA NO.: 029069 VALID UNTIL: December 31, 2009 Sponge Nurse: ________________________________________________ Sponge Nurse: ________________________________________________

ANSAP NO.: 09-0054 VALID UNTIL: December 31, 2009 ______________________ ____________________ ______________________ ____________________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. ____________ PRC No. _________ PRC No. ____________ PRC No. _________

Agency: ____________________________ Level:___________________ Agency: ____________________________ Level:___________________

Name of Patient: _______________________________________________ Name of Patient: _______________________________________________ Name of Patient: _______________________________________________


Address:______________________________________________________ Address:______________________________________________________ Address:______________________________________________________
Age: _________________Sex:____________Ward____________________ Age: _________________Sex:____________Ward____________________ Age: _________________Sex:____________Ward____________________
Case No.: _______________________Date: _________________________ Case No.: _______________________Date: _________________________ Case No.: _______________________Date: _________________________
Pre-op Diagnosis:_______________________________________________ Pre-op Diagnosis:_______________________________________________ Pre-op Diagnosis:_______________________________________________
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Post-op Diagnosis:______________________________________________ Post-op Diagnosis:______________________________________________ Post-op Diagnosis:______________________________________________
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Operation Performed: ___________________________________________ Operation Performed: ___________________________________________ Operation Performed: ___________________________________________
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Time Started:_________________ Time Finished_____________________ Time Started:_________________ Time Finished_____________________ Time Started:_________________ Time Finished_____________________
Surgeon: _____________________________________________________ Surgeon: _____________________________________________________ Surgeon: _____________________________________________________
Assistant:_____________________________________________________ Assistant:_____________________________________________________ Assistant:_____________________________________________________
Anesthesiologist:_______________________________________________ Anesthesiologist:_______________________________________________ Anesthesiologist:_______________________________________________
Type of Anesthesia: ____________________________________________ Type of Anesthesia: ____________________________________________ Type of Anesthesia: ____________________________________________
Anesthesia Started: _____________________________________________ Anesthesia Started: _____________________________________________ Anesthesia Started: _____________________________________________
Instrument Nurse: ______________________________________________ Instrument Nurse: ______________________________________________ Instrument Nurse: ______________________________________________
Sponge Nurse: ________________________________________________ Sponge Nurse: ________________________________________________ Sponge Nurse: ________________________________________________

______________________ ____________________ ______________________ ____________________ ______________________ ____________________


Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. ____________ PRC No. _________ PRC No. ____________ PRC No. _________ PRC No. ____________ PRC No. _________

Agency: ____________________________ Level:___________________ Agency: ____________________________ Level:___________________ Agency: ____________________________ Level:___________________


UNIVERSITY OF PANGASINAN Name of Patient: _______________________________________________ Name of Patient: _______________________________________________
COLLEGE OF NURSING Address:______________________________________________________ Address:______________________________________________________
DAGUPAN CITY Age: _________________Sex:____________Ward____________________ Age: _________________Sex:____________Ward____________________
Case No.: _______________________Date: _________________________ Case No.: _______________________Date: _________________________
MINOR CASE SLIP Pre-op Diagnosis:_______________________________________________ Pre-op Diagnosis:_______________________________________________
_____________________________________________________________ _____________________________________________________________
NAME OF STUDENT: Post-op Diagnosis:______________________________________________ Post-op Diagnosis:______________________________________________
_____________________________________________________________ _____________________________________________________________
STUDENT NUMBER: Operation Performed: ___________________________________________ Operation Performed: ___________________________________________
_____________________________________________________________ _____________________________________________________________
Time Started:_________________ Time Finished_____________________ Time Started:_________________ Time Finished_____________________
Surgeon: _____________________________________________________ Surgeon: _____________________________________________________
ZENAIDA M. BAUTISTA RN, MAN Assistant:_____________________________________________________ Assistant:_____________________________________________________
CLINICAL COORDINATOR Anesthesiologist:_______________________________________________ Anesthesiologist:_______________________________________________
Type of Anesthesia: ____________________________________________ Type of Anesthesia: ____________________________________________
PRC NO.: 0133422 VALID UNTIL: July 27, 2011 Anesthesia Started: _____________________________________________ Anesthesia Started: _____________________________________________
Instrument Nurse: ______________________________________________ Instrument Nurse: ______________________________________________
PNA NO.: 029069 VALID UNTIL: December 31, 2009 Sponge Nurse: ________________________________________________ Sponge Nurse: ________________________________________________

ANSAP NO.: 09-0054 VALID UNTIL: December 31, 2009 ______________________ ____________________ ______________________ ____________________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. ____________ PRC No. _________ PRC No. ____________ PRC No. _________

Agency: ____________________________ Level:___________________ Agency: ____________________________ Level:___________________

Name of Patient: _______________________________________________ Name of Patient: _______________________________________________ Name of Patient: _______________________________________________


Address:______________________________________________________ Address:______________________________________________________ Address:______________________________________________________
Age: _________________Sex:____________Ward____________________ Age: _________________Sex:____________Ward____________________ Age: _________________Sex:____________Ward____________________
Case No.: _______________________Date: _________________________ Case No.: _______________________Date: _________________________ Case No.: _______________________Date: _________________________
Pre-op Diagnosis:_______________________________________________ Pre-op Diagnosis:_______________________________________________ Pre-op Diagnosis:_______________________________________________
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Post-op Diagnosis:______________________________________________ Post-op Diagnosis:______________________________________________ Post-op Diagnosis:______________________________________________
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Operation Performed: ___________________________________________ Operation Performed: ___________________________________________ Operation Performed: ___________________________________________
_____________________________________________________________ _____________________________________________________________ _____________________________________________________________
Time Started:_________________ Time Finished_____________________ Time Started:_________________ Time Finished_____________________ Time Started:_________________ Time Finished_____________________
Surgeon: _____________________________________________________ Surgeon: _____________________________________________________ Surgeon: _____________________________________________________
Assistant:_____________________________________________________ Assistant:_____________________________________________________ Assistant:_____________________________________________________
Anesthesiologist:_______________________________________________ Anesthesiologist:_______________________________________________ Anesthesiologist:_______________________________________________
Type of Anesthesia: ____________________________________________ Type of Anesthesia: ____________________________________________ Type of Anesthesia: ____________________________________________
Anesthesia Started: _____________________________________________ Anesthesia Started: _____________________________________________ Anesthesia Started: _____________________________________________
Instrument Nurse: ______________________________________________ Instrument Nurse: ______________________________________________ Instrument Nurse: ______________________________________________
Sponge Nurse: ________________________________________________ Sponge Nurse: ________________________________________________ Sponge Nurse: ________________________________________________

______________________ ____________________ ______________________ ____________________ ______________________ ____________________


Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. ____________ PRC No. _________ PRC No. ____________ PRC No. _________ PRC No. ____________ PRC No. _________

Agency: ____________________________ Level:___________________ Agency: ____________________________ Level:___________________ Agency: ____________________________ Level:___________________


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING Name of Patient: ______________________________ Name of Patient: ______________________________
DAGUPAN CITY Address:_____________________________________ Address:_____________________________________
Age: ________________Case No.________________ Age: ________________Case No.________________
ACTUAL CASE SLIP
Gravida: _____________Para: ___________________ Gravida: _____________Para: ___________________
NAME OF STUDENT: Date of Delivery:______________________________ Date of Delivery:______________________________
Gender of Baby:_______________________________ Gender of Baby:_______________________________
STUDENT NUMBER:
Time of Delivery: _____________________________ Time of Delivery: _____________________________
Type of Delivery:______________________________ Type of Delivery:______________________________
Diagnosis: ___________________________________ Diagnosis: ___________________________________
ZENAIDA M. BAUTISTA RN, MAN
CLINICAL COORDINATOR ____________________________________________ ____________________________________________
Obstetrician:__________________________________ Obstetrician:__________________________________
PRC NO.: 0133422 VALID UNTIL: July 27, 2011

PNA NO.: 029069 VALID UNTIL: December 31, 2009 _________________ _______________ _________________ _______________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
ANSAP NO.: 09-0054 VALID UNTIL: December 31, 2009 PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______

Agency: ______________________Level___________ Agency: ______________________Level___________

Name of Patient: ______________________________ Name of Patient: ______________________________ Name of Patient: ______________________________


Address:_____________________________________ Address:_____________________________________ Address:_____________________________________
Age: ________________Case No.________________ Age: ________________Case No.________________ Age: ________________Case No.________________
Gravida: _____________Para: ___________________ Gravida: _____________Para: ___________________ Gravida: _____________Para: ___________________
Date of Delivery:______________________________ Date of Delivery:______________________________ Date of Delivery:______________________________
Gender of Baby:_______________________________ Gender of Baby:_______________________________ Gender of Baby:_______________________________
Time of Delivery: _____________________________ Time of Delivery: _____________________________ Time of Delivery: _____________________________
Type of Delivery:______________________________ Type of Delivery:______________________________ Type of Delivery:______________________________
Diagnosis: ___________________________________ Diagnosis: ___________________________________ Diagnosis: ___________________________________
____________________________________________ ____________________________________________ ____________________________________________
Obstetrician:__________________________________ Obstetrician:__________________________________ Obstetrician:__________________________________

_________________ _______________ _________________ _______________ _________________ _______________


Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______

Agency: ______________________Level___________ Agency: ______________________Level___________ Agency: ______________________Level___________


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING Name of Patient: ______________________________ Name of Patient: ______________________________
DAGUPAN CITY Address:_____________________________________ Address:_____________________________________
Age: ________________Case No.________________ Age: ________________Case No.________________
ASSISTED CASE SLIP
Gravida: _____________Para: ___________________ Gravida: _____________Para: ___________________
NAME OF STUDENT: Date of Delivery:______________________________ Date of Delivery:______________________________
Gender of Baby:_______________________________ Gender of Baby:_______________________________
STUDENT NUMBER:
Time of Delivery: _____________________________ Time of Delivery: _____________________________
Type of Delivery:______________________________ Type of Delivery:______________________________
Diagnosis: ___________________________________ Diagnosis: ___________________________________
ZENAIDA M. BAUTISTA RN, MAN
CLINICAL COORDINATOR ____________________________________________ ____________________________________________
Obstetrician:__________________________________ Obstetrician:__________________________________
PRC NO.: 0133422 VALID UNTIL: July 27, 2011

PNA NO.: 029069 VALID UNTIL: December 31, 2009 _________________ _______________ _________________ _______________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
ANSAP NO.: 09-0054 VALID UNTIL: December 31, 2009 PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______

Agency: ______________________Level___________ Agency: ______________________Level___________

Name of Patient: ______________________________ Name of Patient: ______________________________ Name of Patient: ______________________________


Address:_____________________________________ Address:_____________________________________ Address:_____________________________________
Age: ________________Case No.________________ Age: ________________Case No.________________ Age: ________________Case No.________________
Gravida: _____________Para: ___________________ Gravida: _____________Para: ___________________ Gravida: _____________Para: ___________________
Date of Delivery:______________________________ Date of Delivery:______________________________ Date of Delivery:______________________________
Gender of Baby:_______________________________ Gender of Baby:_______________________________ Gender of Baby:_______________________________
Time of Delivery: _____________________________ Time of Delivery: _____________________________ Time of Delivery: _____________________________
Type of Delivery:______________________________ Type of Delivery:______________________________ Type of Delivery:______________________________
Diagnosis: ___________________________________ Diagnosis: ___________________________________ Diagnosis: ___________________________________
____________________________________________ ____________________________________________ ____________________________________________
Obstetrician:__________________________________ Obstetrician:__________________________________ Obstetrician:__________________________________

_________________ _______________ _________________ _______________ _________________ _______________


Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______

Agency: ______________________Level___________ Agency: ______________________Level___________ Agency: ______________________Level___________


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING Name of Patient: ______________________________ Name of Patient: ______________________________
DAGUPAN CITY
Case No. ________________Gender: _____________ Case No. ________________Gender: _____________
CORD CASE SLIP
Name of Mother:______________________________ Name of Mother:______________________________
NAME OF STUDENT:
Address:_____________________________________ Address:_____________________________________
STUDENT NUMBER:
Date of Delivery:______________________________ Date of Delivery:______________________________
Time of Delivery: _____________________________ Time of Delivery: _____________________________
ZENAIDA M. BAUTISTA RN, MAN
CLINICAL COORDINATOR Type of Delivery:______________________________ Type of Delivery:______________________________

PRC NO.: 0133422 VALID UNTIL: July 27, 2011 Pediatrician:__________________________________ Pediatrician:__________________________________

PNA NO.: 029069 VALID UNTIL: December 31, 2009 _________________ _______________ _________________ _______________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
ANSAP NO.: 09-0054 VALID UNTIL: December 31, 2009 PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______

Agency: ______________________Level___________ Agency: ______________________Level___________

Name of Patient: ______________________________ Name of Patient: ______________________________


Name of Patient: ______________________________
Case No. ________________Gender: _____________ Case No. ________________Gender: _____________
Case No. ________________Gender: _____________
Name of Mother:______________________________ Name of Mother:______________________________
Name of Mother:______________________________
Address:_____________________________________ Address:_____________________________________
Address:_____________________________________
Date of Delivery:______________________________ Date of Delivery:______________________________
Date of Delivery:______________________________
Time of Delivery: _____________________________ Time of Delivery: _____________________________
Time of Delivery: _____________________________
Type of Delivery:______________________________ Type of Delivery:______________________________
Type of Delivery:______________________________
Pediatrician:__________________________________ Pediatrician:__________________________________
Pediatrician:__________________________________
_________________ _______________ _________________ _______________
_________________ _______________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
Staff Nurse on Duty Nurse Instructor
PRC No. _________ PRC No. _______ PRC No. _________ PRC No. _______
PRC No. _________ PRC No. _______
Agency: ______________________Level___________ Agency: ______________________Level___________
Agency: ______________________Level___________

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