Sample Exhibit Form

Ateneo de Zamboanga University COLLEGE OF NURSING Zamboanga City Prepared by: FAMI, FIRST SECOND MIDDLE Name and
Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Date When School Program was recognized: CHED Memorandum No.1 series of 2005 First Course: Not applicable Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year Graduated (BSN Program): March 2011 ___________________________ NAME OF STUDENT MAJOR OPERATION No . Date of Operation Case No. Name of Patient Diagnosis Operation Performed Anesthesia Name of Surgeon Name of Hospital Name and Signature of Scrub Nurse Name and Signature of Qualified CI Year Granted: May 05, 2008-2013 School Graduated From: Ateneo de Zamboanga University Year: Not Applicable
Noted by: Flor P. San Luis, RN, MN Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master in Nursing Date signed: PRC I.D. No. 0062360 PNA No. 017407 ANSAP I.D. No. 006547 Valid Until : January 29, 2011 Valid Until : November 12, 2010 Valid Until: January 3, 2012 Approved by: Maria Lorna Bello-Paber, R.N., M.A.N.
Concurred by: Evelyn Tindick-Monsanto, R.N., MEd., M.N. Chief Nurse, Zamboanga City Medical Center Highest Nursing Degree Earned Bachelor of Science in Nursing Master in Education Master in Nursing Date signed: PRC I.D. No. 0063627 Valid until: December 12, 2012 PNA No. 2927 Valid until: Life Member ANSAP No. 0381 Valid until: Life Member
Dean, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master of Arts in Nursing Date signed: PRC No. 0059150 Valid Until : September 15, 2010 PNA No. 6141 Valid Until : Lifetime Member ADPCN No. 0655 Valid Until : December 31, 2010
Ateneo de Zamboanga University COLLEGE OF NURSING La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013 CHED Memorandum No.1 series of 2005 Surgical Scrub in _______________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student: _ _______________________________________________________ ________________________________________________________________ Date Performed and Time Started Patients Name Case Number
ODC Form 1 O.R. SCRUB From Major
Signature of Student: SUPERVISED BY: CLINICAL INSTRUCTOR NAME AND SIGNATURE
PROCEDURE PERFORMED
O.R. NURSE ON DUTY (NAME ONLY)
Noted by: Flor P. San Luis, RN, MN Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master in Nursing Date signed: PRC I.D. No. 0062360 PNA No. 017407 ANSAP I.D. No. 006547 Valid Until : January 29, 2011 Valid Until : November 12, 2010 Valid Until: January 3, 2012
Approved by: Maria Lorna Bello-Paber, R.N., M.A.N. Dean, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master of Arts in Nursing Date signed: PRC No. 0059150 Valid Until : September 15, 2010 PNA No. 6141 Valid Until : Lifetime Member ADPCN No. 0655 Valid Until : December 31, 2010
Ateneo de Zamboanga University COLLEGE OF NURSING Zamboanga City Prepared by: FAMI, FIRST SECOND MIDDLE Name and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Date When School Program was recognized: CHED Memorandum No.1 series of 2005 First Course: Not applicable Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year Graduated (BSN Program): March 2011 ___________________________ NAME OF STUDENT MINOR OPERATION No . Date of Operation Case No. Name of Patient Diagnosis Operation Performed Anesthesia Name of Surgeon Name of Hospital Name and Signature of Scrub Nurse Name and Signature of Qualified CI
Year Granted: May 05, 2008-2013 School Graduated From: Ateneo de Zamboanga University Year: Not Applicable
Ateneo de Zamboanga University COLLEGE OF NURSING La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013 CHED Memorandum No.1 series of 2005 Surgical Scrub in _______________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student: _____________________________________________ Date Performed and Time Started Patients Name Case Number
ODC Form 2 O.R. SCRUB From Minor
_____________ Signature of Student: ________________________________________________________ PROCEDURE PERFORMED O.R. NURSE ON DUTY (NAME ONLY) SUPERVISED BY: CLINICAL INSTRUCTOR NAME AND SIGNATURE
Ateneo de Zamboanga University COLLEGE OF NURSING Zamboanga City Prepared by: FAMI, FIRST SECOND MIDDLE Name and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Date When School Program was recognized: CHED Memorandum No.1 series of 2005 First Course: Not applicable Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year Graduated (BSN Program): March 2011 ___________________________ NAME OF STUDENT ACTUAL DELIVERIES No. Case No. Diagnosis Name of Patient Age Date of Delivery Time of Delivery Gender of the Baby Name of Hospital Type of Delivery Name & Signature of Qualified C.I.
Ateneo de Zamboanga University COLLEGE OF NURSING La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013 CHED Memorandum No.1 series of 2005 Surgical Scrub in _______________________________________ Hospital, Municipality/City/Province Prepared by: Name of Student: _ ___________________ _______________________________ Date Performed and Time Started Patients Name Case Number (not applicable for Birthing/lyingin Clinics/Homes)
ODC Form 3 ACTUAL DELIVERY FORM
Signature of Student: ________________________________________________________________ O.R. NURSE ON DUTY (NAME ONLY) SUPERVISED BY: CLINICAL INSTRUCTOR NAME AND SIGNATURE
PROCEDURE PERFORMED
Ateneo de Zamboanga University COLLEGE OF NURSING Zamboanga City Prepared by: FAMI, FIRST SECOND MIDDLE Name and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Date When School Program was recognized: CHED Memorandum No.1 series of 2005 First Course: Not applicable Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year Graduated (BSN Program): March 2011 ___________________________ NAME OF STUDENT DELIVERIES ASSISTED No. Case No. Diagnosis Name of Patient Age Date of Delivery Time of Delivery Gender of the Baby
Name of Hospital
Type of Delivery
Name & Signature of Qualified C.I.
Ateneo de Zamboanga University COLLEGE OF NURSING La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013 CHED Memorandum No.1 series of 2005 Surgical Scrub in _______________________________________ Hospital, Municipality/City/Province
ODC Form 4 D.R. ASSIST FORM
Prepared by: Name of Student: _ _______________________ _______________________________ Signature of Student: ________________________________________________________________ Date Performed and Time Started Patients Name Case Number (not applicable for Birthing/lyingin Clinics/Homes) PROCEDURE PERFORMED O.R. NURSE ON DUTY (NAME ONLY) SUPERVISED BY: CLINICAL INSTRUCTOR NAME AND SIGNATURE
Noted by: Flor P. San Luis, RN, MN Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master in Nursing
Concurred by: Evelyn Tindick-Monsanto, R.N., MEd., M.N. Chief Nurse, Zamboanga City Medical Center Master in Education Master in Nursing
Date signed: PRC I.D. No. 0062360 PNA No. 017407 ANSAP I.D. No. 006547
Valid Until : November 12, 2010 Valid Until: January 3, 2012 Approved by: Maria Lorna Bello-Paber, R.N., M.A.N.
Date signed: Valid Until : January 29, 2011 PNA No. 2927 ANSAP No. 0381
Valid until: Life Member Valid until: Life Member
Ateneo de Zamboanga University COLLEGE OF NURSING Zamboanga City Prepared by: FAMI, FIRST SECOND MIDDLE Name and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Date When School Program was recognized: CHED Memorandum No.1 series of 2005 First Course: Not applicable Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year Graduated (BSN Program): March 2011 ___________________________ NAME OF STUDENT CORD DRESSING No. Case No. Date Performed Name of the Baby Gender of the Baby Name of the Mother Age of the Mother Name of Hospital Name & Signature of Qualified C.I.
Noted by: Flor P. San Luis, RN, MN Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master in Nursing Date signed: PRC I.D. No. 0062360 PNA No. 017407 ANSAP I.D. No. 006547
Concurred by: Evelyn Tindick-Monsanto, R.N., MEd., M.N. Chief Nurse, Zamboanga City Medical Center Master in Education Master in Nursing Date signed: Valid Until : January 29, 2011 PNA No. 2927 ANSAP No. 0381 Valid until: Life Member Valid until: Life Member
Ateneo de Zamboanga University COLLEGE OF NURSING La Purisima Street, Zamboanga City Recognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013 CHED Memorandum No.1 series of 2005 Surgical Scrub in _______________________________________ Hospital, Municipality/City/Province
ODC Form 5 D.R. CORD CARE FORM
Prepared by: Name of Student: _ _____________________________________________________ Signature of Student: ________________________________________________________________ Date Performed and Time Started Patients Name Case Number (not applicable for Birthing/lyingin Clinics/Homes) PROCEDURE PERFORMED O.R. NURSE ON DUTY (NAME ONLY) SUPERVISED BY: CLINICAL INSTRUCTOR NAME AND SIGNATURE
Noted by: Flor P. San Luis, RN, MN Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing Master in Nursing Date signed: PRC I.D. No. 0062360 PNA No. 017407 ANSAP I.D. No. 006547
Concurred by: Evelyn Tindick-Monsanto, R.N., MEd., M.N. Chief Nurse, Zamboanga City Medical Center Master in Education Master in Nursing Date signed: Valid Until : January 29, 2011 PNA No. 2927 ANSAP No. 0381 Valid until: Life Member Valid until: Life Member
PRC NUMBERS:
For Zamboanga City Medical Center
Noted by: Flor P. San Luis, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & time document is signed: ______________ Time: ___________ PRC I.D. No: 0062360 Valid until: January 29, 2011 PNA No. 017407 Valid Until: December 31, 2010 Concurred by: Evelyn Tindick-Monsanto, RN, Med, MN Chief Nurse, Zamboanga City Medical Center Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Education Master in Nursing Date & time document is signed: ______________ Time: ______ PRC I.D. No. 0063627 Valid Until: December 12, 2009 PNA No. 2927 Valid Until: Life Member ANSAP No. 0381 Valid Until: Life Member
Approved by: Maria Lorna Bello- Paber, RN, MAN Dean, ADZU College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & time document is signed: ______________ Time: ___________ PRC No.: 0069150 Valid Until: September 15, 2010 PNA No. 6141 Valid Until: Lifetime Member ADPCN No. 0655 Valid Until: December 31, 2009
For Ciudad Medical Zamboanga

Noted by: Ma. Lourdes Concepcion-Follero, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & time document is signed: ____________________ Time: _____ PRC I.D. No: 0115066 Valid Until: December 06, 2011 PNA No. 016740 Valid Until: December 31, 2009 Concurred by: Celita P. Calma, RN, MAN Chief Nurse, Ciudad Medical Zamboanga Highest Nursing Degree Earned: Bachelor of Science in Nursing Master of Arts in Nursing Date & time document is signed: ______________ Time: ______ PRC I.D. No. 069666 Valid Until: March 9, 2012 PNA No. 18799 Valid Until: Lifetime Member ANSAP No. 01038 Valid Until: December 31, 2009
Approved by: Maria Lorna Bello- Paber, RN, MAN Dean, ADZU College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & time document is signed: ______________ Time: ___________ PRC No.: 0069150 Valid Until: September 15, 2010 PNA No. 6141 Valid Until: Lifetime Member
ADPCN No. 0655
Valid Until: December 31, 2009
For Zamboanga Doctors Hospital

Noted by: Ma. Lourdes Concepcion-Follero, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & time document is signed: ____________________ Time: ___________ PRC I.D. No. 0115066 Valid until December 06, 2011 PNA No. 016740 Valid Until: December 31, 2009 Concurred by: Maria Bella M. Tandoc, RN, MAN Chief Nurse, Zamboanga Doctors Hospital Highest Nursing Degree Earned: Bachelor of Science in Nursing Master of Arts in Nursing Date & time document is signed: ______________ Time: ______ PRC I.D. No. 0041245 Valid Until::February 04, 2010 PNA No. 12434 Valid Until: Lifetime Member ANSAP No. Valid Until: December 31, 2009
For Western Mindanao Medical Center

Noted by: Ma. Lourdes Concepcion-Follero, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & time document is signed: ____________________ Time: ___________ PRC I.D. No. 0115066 Valid until: December 06, 2011 PNA No. 016740 Valid Until: December 31, 2009 Concurred by: Ma. Dolores B. Pacatang, RN Chief Nurse, Western Mindanao Medical Center Highest Nursing Degree Earned: Bachelor of Science in Nursing Date & time document is signed: ______________ Time: ______ PRC I.D. No. 074214 Valid Until::February 2, 2011 PNA No. 18033 Valid Until: Lifetime Member ANSAP No. 02629 Valid Until: December 31, 2009
For Zamboanga Puericulture Lying-In Maternity Hospital

Noted by: Ma. Lourdes Concepcion-Follero, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & TIME document is signed: ____________________ Time: ___________ PRC I.D. No. 0115066 Valid until December 06, 2011 PNA No. 016740 Valid Until: December 31, 2009 Concurred by: Ma. Theresa Geraldine Pioquinto, RN Chief Nurse, ZPMH Highest Nursing Degree Earned: Bachelor of Science in Nursing Date & TIME document is signed: ______________ Time: ______ PRC I.D. No. 0177945 Valid Until::October 11, 2011 PNA No. 016531 Valid Until: December 31, 2009
For DOS
Noted by: Ma. Lourdes Concepcion-Follero, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing Master in Nursing Date & TIME document is signed: ____________________ Time: ___________ PRC I.D. No. 0115066 Valid until December 06, 2011 PNA No. 016740 Valid Until: December 31, 2009
1. PAASCU Level II Re-accredited Status Year granted: January 31, 2009 to November 2011 2. Chief nurse of PDMMC Salomia S. Dela Cruz PRC validity: November 2011 3. HOSPITAL NAMES: St. Clare's Medical Center Taguig City Hospital Jose Reyes Memorial Medical Center 4. NAME OF PATIENT SHOULD BE INITIALS ONLY example: Celeste B. Vidal- - - C.B.V. (no spaces) 5. NAME OF BABY (CORD CARE) BABY + INITIALS OF MOTHER example: Baby C.B.V. 6. FIRST COURSE: Not Applicable School Graduated from: Not Applicable 7. CLINICAL COORDINATOR: Evelyn J. Torio NAME: Calma, Jamie Lyn Vinluan NAME & ADD OF SCHOOL: Manila Doctors College, President Diosdado Macapagal Blvd., Metropolitan Park, Pasay City *No abbreviations *Yung Doctors daw dapat may first name accdg to our president *Put an underline on top of the Scrub nurse's name *CAPITALIZE AM / PM *Gender of baby: BOY / GIRL (for uniformity purposes) *FORMAT OF DR DX: example: Pregnancy Uterine, Full Term, 39 Weeks Age of Gestation, Cephalic in Labor, Gravida 2 Parity 1 *dates: example: March 27, 2010 *No anesthesia word in type of anesthesia

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Sample Exhibit Form

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Copyright:

Verfügbare Formate

Ateneo de Zamboanga University COLLEGE OF NURSING Zamboanga City Prepared by: FAMI, FIRST SECOND MIDDLE Name and

ODC Form 1 O.R. SCRUB From Major

Signature of Student: SUPERVISED BY: CLINICAL INSTRUCTOR NAME AND SIGNATURE

O.R. NURSE ON DUTY (NAME ONLY)

ODC Form 2 O.R. SCRUB From Minor

ODC Form 3 ACTUAL DELIVERY FORM

Name & Signature of Qualified C.I.

ODC Form 4 D.R. ASSIST FORM

Valid until: Life Member Valid until: Life Member

ODC Form 5 D.R. CORD CARE FORM

For Ciudad Medical Zamboanga

ADPCN No. 0655

Valid Until: December 31, 2009

For Zamboanga Doctors Hospital

For Western Mindanao Medical Center

For Zamboanga Puericulture Lying-In Maternity Hospital

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