LIPA CITY COLLEGES

# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, lcc@lipacitycolleges.net, www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) SURGICAL SCRUB (MAJOR) in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 1
OR SCRUB FORM

Signature of Student ___________________________________

PROCEDURE PERFORMED

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 002454 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2012 PNA No.: 002453 Valid Until: DECEMBER 2010 ADPCN No.: 172 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2012 PNA No.: 03296 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES

# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, lcc@lipacitycolleges.net, www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) SURGICAL SCRUB (MINOR) in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 2
OR SCRUB FORM

Signature of Student ___________________________________

PROCEDURE PERFORMED

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________Time: __________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 ADPCN No.: 172 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: _____________________Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES

# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, lcc@lipacitycolleges.net, www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) ACTUAL DELIVERY in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 3
DR ACTUAL DELIVERY

Signature of Student ______________________________

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ , R.N., M.A.N. Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT, R.N., M.A.N., Ed.D Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2010 PNA No.: 03208 Valid Until: DECEMBER 2009 ADPCN No.: 172 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES

# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, lcc@lipacitycolleges.net, www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) ASSISTED DELIVERY in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student _____________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 4
DR ASSIST

Signature of Student ___________________________________

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ , R.N., M.A.N. Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 02454 Valid Until: OCTOBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ___________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT, R.N., M.A.N., Ed.D Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2010 PNA No.: 02453 Valid Until: OCTOBER 2010 ADPCN No.: 172 Valid Until: DECEMBER 2012 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N. Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ___________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

LIPA CITY COLLEGES

# 10 G.A. Solis St., Lipa City, Batangas (043) 756-1943, (043) 756-3768, (043) 756-5974, lcc@lipacitycolleges.net, www.lipacitycolleges.net (CHED RECOGNIZED No. 11, 1992/ PACUCOA ACCREDITED: LEVEL I STATUS, January 9, 2009-2011) IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student ______________________________________________________ Date Performed and Time Started Patients Name Case Number

ODC Form 5
IMMEDIATE NEWBORN CORD CARE

Signature of Student ___________________________________

Immediate Newborn Cord Care PERFORMED

Indicate where performed (e.g. DR, NICU, Nursery, or Home)

D.R. Nurse/Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RUBY G. DELA CRUZ , R.N., M.A.N. Clinical Coordinator, PRC I.D. No.: 0360712 Valid Until: NOVEMBER 2010 PNA No.: 02454 Valid Until: OCTOBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ______________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Approved by: DULCE I. LIBUIT, R.N., M.A.N., Ed.D Dean, PRC I.D. No.: 0196088 Valid Until: OCTOBER 2012 PNA No.: 02453 Valid Until: OCTOBER 2010 ADPCN No.: 172 Valid Until: DECEMBER 2010 Date document is signed: ______________________ Time: _________________ Please specify Highest Nursing Degree Earned: Ed.D

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: _____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.

Concurred by: GLADY EDITH T. TECSON, R.N., M.A.N. Chief Nurse, PRC I.D. No.: 0148202 Valid Until: NOVEMBER 2009 PNA No.: 056972 Valid Until: DECEMBER 2009 Date document is signed: ____________________ Time: ___________ Please specify Highest Nursing Degree Earned: M.A.N.