Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES

COLLEGE OF NURSING
Tamag, Vigan City, Ilocos Sur
Telefax: (077) 722-7212/unp_op@yahoo.com, www.unp.edu.ph
Level II Re-Accredited Status (March 13, 2000 March 12, 2005)
SURGICAL SCRUB in ____________________________________________
(Hospital, Municipality/City/Province)
O.R. Form 1A

Prepared by:

O.R. SCRUB FORM

Major

Printed Name with Signature of Student _________________________________________________________

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

SURGICAL
PROCEDURE PERFORMED

SUPERVISED BY:
Clinical Instructor
Name and Signature

O.R. Nurse On Duty

(Name and Signature)

Noted by: _______________________________________________________

(Print Name and Signature)

Approved by: ___________________________________________________

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. _________________

Valid Until ___________

Dean, PRC I.D. No. ______________________

Date document is signed: __________________________

Time: _______________

Date document is signed: __________________________

Highest Nursing Degree Earned: ____________________________________________

Valid Until ____________________

Time: _______________

Highest Nursing Degree Earned: ____________________________________________

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
COLLEGE OF NURSING
Tamag, Vigan City, Ilocos Sur
Telefax: (077) 722-7212/unp_op@yahoo.com, www.unp.edu.ph
Level II Re-Accredited Status (March 13, 2000 March 12, 2005)
SURGICAL SCRUB in ____________________________________________
(Hospital, Municipality/City/Province)
Prepared by:

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

Printed Name with Signature of Student _________________________________________________________

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

SURGICAL
PROCEDURE PERFORMED

SUPERVISED BY:
Clinical Instructor
Name and Signature

O.R. Nurse On Duty

(Name and Signature)

Noted by: _______________________________________________________

(Print Name and Signature)

Approved by: ___________________________________________________

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. _________________

Valid Until ___________

Dean, PRC I.D. No. ______________________

Date document is signed: __________________________

Time: _______________

Date document is signed: __________________________

Highest Nursing Degree Earned: ____________________________________________

Valid Until ____________________

Time: _______________

Highest Nursing Degree Earned: ____________________________________________

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
COLLEGE OF NURSING
Tamag, Vigan City, Ilocos Sur
Telefax: (077) 722-7212/unp_op@yahoo.com, www.unp.edu.ph
Level II Re-Accredited Status (March 13, 2000 March 12, 2005)
ACTUAL DELIVERY in _____________________________________________________
(Hospital/Home/Lying-In Clinic, Municipality/City/Province)

Prepared by:
D.R. Form

Printed Name with Signature of Student _________________________________________________________

ACTUAL DELIVERY FORM

Patients Name
Date Performed
and
Time Started

Case Number

PROCEDURE PERFORMED

D.R. Nurse On Duty

(Name only)

SUPERVISED BY:
Clinical Instructor
Name and Signature

(not applicable for Birthing/Lying-In

Clinics/Homes)

Noted by: _______________________________________________________

(Print Name and Signature)

Approved by: ___________________________________________________

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. _________________

Valid Until ___________

Dean, PRC I.D. No. ______________________

Date document is signed: __________________________

Time: _______________

Date document is signed: __________________________

Highest Nursing Degree Earned: ____________________________________________

Valid Until ____________________

Time: _______________

Highest Nursing Degree Earned: ____________________________________________

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
COLLEGE OF NURSING
Tamag, Vigan City, Ilocos Sur
Telefax: (077) 722-7212/unp_op@yahoo.com, www.unp.edu.ph
Level II Re-Accredited Status (March 13, 2000 March 12, 2005)
ASSISTED DELIVERY in _____________________________________________________
(Hospital/Home/Lying-In Clinic, Municipality/City/Province)

Prepared by:
D.R. Form

Printed Name with Signature of Student _________________________________________________________

Patients INITIALS (only)

Date Performed
and
Time Started

Case Number

PROCEDURE PERFORMED

(not applicable for Birthing/Lying-In

Clinics/Homes)

ASSISTED DELIVERY FORM

D.R. Nurse On Duty

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

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: _______________________________________________________

(Print Name and Signature)

Approved by: ___________________________________________________

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. _________________

Valid Until ___________

Dean, PRC I.D. No. ______________________

Date document is signed: __________________________

Time: _______________

Date document is signed: __________________________

Highest Nursing Degree Earned: ____________________________________________

Valid Until ____________________

Time: _______________

Highest Nursing Degree Earned: ____________________________________________

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
COLLEGE OF NURSING
Tamag, Vigan City, Ilocos Sur
Telefax: (077) 722-7212/unp_op@yahoo.com, www.unp.edu.ph
Level II Re-Accredited Status (March 13, 2000 March 12, 2005)
IMMEDIATE NEWBORN CORD CARE in _____________________________________________________
(Hospital/Home/Lying-In Clinic, Municipality/City/Province)

Prepared by:
ICNB Form
Printed Name with Signature of Student _________________________________________________________

Patients INITIALS (only)

Date Performed
and
Time Started

Case Number
(not applicable for Birthing/Lying-In
Clinics/Homes)

Immediate Newborn Cord Care

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

IMMEDIATE CARE OF THE

NEWBORN FORM

D.R. Nurse On Duty

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

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: _______________________________________________________

(Print Name and Signature)

Approved by: ___________________________________________________

(Print Name and Signature)

Clinical Coordinator, PRC I.D. No. _________________

Valid Until ___________

Dean, PRC I.D. No. ______________________

Date document is signed: __________________________

Time: _______________

Date document is signed: __________________________

Highest Nursing Degree Earned: ____________________________________________

Valid Until ____________________

Time: _______________

Highest Nursing Degree Earned: ____________________________________________