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ARRIESGADO COLLEGE FOUNDATION INC.

ODC FORM 1A ACTUAL


DELIVERY FORM

COLLEGE OF NURSING
201 Bonifacio Street, Tagum City
Email:vincentarriesgado@yahoo.com.ph
Tel. No. (084) 655-6583, (084) 655-6641

ACTUAL DELIVERY in :

Southern Philippines Medical Center, JP laurel Ave, Bajada, Davao City, Davao del Sur__
Hospital, Municipality/City/Province

Prepared by:________DAISY ANN RADA IIGO________


Printed Name and Signature of Students

DATE PERFORMED AND TIME


STARTED

PATIENTS INITIAL ONLY


CASE NUMBER
(NOT APPLICABLE FOR
BIRTHING HOMES/ LYING-IN
CLINICS/HOMES)

February 25, 2013


09:48am

B.D.A.
2488959

February 25, 2013


01:09pm
March !3, 2013
11:05am

D.R. NURSE ON DUTY


(NAME AND SIGNATURE)
(IF MIDWIFE ON DUTY,
SIGNATURE NOT REQUIRED)

SUPERVISED BY:
CLINICAL INSTRUCTOR
NAME AND SIGNATURE

Normal Spontaneous Vaginal


Delivery

Jermalyn C. Gadiano, RN
Lic. No. 0458308

Allen Celier Yecyec, RN


Lic. No. 0355774

F.C.M.
2489196

Normal Spontaneous Vaginal


Delivery

Jermalyn C. Gadiano, RN
Lic. No. 0458308

Allen Celier Yecyec, RN


Lic. No. 0355774

S.M.P.
2478634

Normal Spontaneous Vaginal


Delivery

Delgie Mae C. Diokno


Lic. No. 0458120

Allen Celier Yecyec, RN


Lic. No. 0355774

PROCEDURE PERFORMED

Noted by__________________________________________________________________
(Print Name and Signature)

CLINICAL COORDINATOR, PRC I.D. No._____________ Valid Until: __________


Date document is signed: _____________________ Time: ________________________
Please specify Highest Nursing Degree Earned: __________________________________

Subscribed and sworn before me this _____ day ______________ of 2012 affiant
Exhibits to me his/her Community Tax Cert. # ___________ issued at __________
issued on_____________________________________

Approved By___________________________________________________________
(Printed Name and Signature)

DEAN, PRC I.D. No. ___________________ Valid Until: ______________ _______


Date document is signed: ________________ Time: _________________________
Please specify Highest Nursing Degree Earned:_________________________________

ARRIESGADO COLLEGE FOUNDATION INC.


ODC FORM 1B ASSISTED
DELIVERY FORM

COLLEGE OF NURSING
201 Bonifacio Street, Tagum City
Email:vincentarriesgado@yahoo.com.ph
Tel. No. (084) 655-6583, (084) 655-6641

ASSISTED DELIVERY in: Southern Philippines Medical Center, JP laurel Ave, Bajada, Davao City, Davao del Sur__
Hospital, Municipality/City/Province
Prepared by: ________DAISY ANN RADA IIGO________
Printed Name and Signature of Students
Patients INITIAL only
Case Number
(not applicable for Birthing Homes/
Lying-in Clinics/Homes)

PROCEDURE PERFORMED

February 27, 2013


09:48am

B.M.A.
2489712

March 13, 2013


09:02am
March 13, 2013
12:39pm

Date Performed and Time Started

D.R. Nurse on Duty


(Name and Signature)
(If Midwife on Duty, signature not
required)

Supervised by:
Clinical Instructor
Name and Signature

Normal Spontaneous Vaginal


Delivery

Maria Teresa C. Guitguiten, RN


Lic. No. 0332669

Allen Celier Yecyec, RN


Lic. No. 0355774

L.S.
2493716

Normal Spontaneous Vaginal


Delivery

Delgie Mae C. Diokno


Lic. No. 0458120

Allen Celier Yecyec, RN


Lic. No. 0355774

B.C.O.
2492397

Normal Spontaneous Vaginal


Delivery

Delgie Mae C. Diokno


Lic. No. 0458120

Allen Celier Yecyec, RN


Lic. No. 0355774

Noted by__________________________________________________________________
(Print Name and Signature)

CLINICAL COORDINATOR, PRC I.D. No._____________ Valid Until: __________


Date document is signed: _____________________ Time: ________________________
Please specify Highest Nursing Degree Earned: __________________________________

Subscribed and sworn before me this _____ day ______________ of 2012 affiant
Exhibits to me his/her Community Tax Cert. # ___________ issued at __________
issued on_____________________________________

Approved By___________________________________________________________
(Printed Name and Signature)

DEAN, PRC I.D. No. ___________________ Valid Until: ______________ _______


Date document is signed: ________________ Time: _________________________
Please specify Highest Nursing Degree Earned:_________________________________

ARRIESGADO COLLEGE FOUNDATION INC.


ODC FORM 1C
CORD CARE FORM

COLLEGE OF NURSING
201 Bonifacio Street, Tagum City
Email:vincentarriesgado@yahoo.com.ph
Tel. No. (084) 655-6583, (084) 655-6641

ASSISTED DELIVERY in: Southern Philippines Medical Center, JP laurel Ave, Bajada, Davao City, Davao del Sur__
Hospital, Municipality/City/Province
Prepared by: ________DAISY ANN RADA IIGO________
Printed Name and Signature of Students
Date Performed and Time Started

Patients INITIAL only


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

Immediate Newborn Cord 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

January 29,2013
10:51am

Baby Boy C.C.D.


2481144

Neonatal Intensive Care Unit

Leah Rhiza H. Maslog, RN


Lic. No. 0370561

Catherine P. Cantalejo, RN, MAN


Lic. No. 0243497

January 29,2013
01:27pm

Baby Girl E.A.


2481204

Neonatal Intensive Care Unit

Leah Rhiza H. Maslog, RN


Lic. No. 0370561

Catherine P. Cantalejo, RN, MAN


Lic. No. 0243497

February 25, 2013


01:33pm

Baby Boy B.C.

Delivery Room

Jermalyn C. Gadiano, RN
Lic. No. 0458308

Allen Celier Yecyec, RN


Lic. No. 0355774

Noted by__________________________________________________________________
(Print Name and Signature)

CLINICAL COORDINATOR, PRC I.D. No._____________ Valid Until: __________


Date document is signed: _____________________ Time: ________________________
Please specify Highest Nursing Degree Earned: __________________________________

Subscribed and sworn before me this _____ day ______________ of 2012 affiant
Exhibits to me his/her Community Tax Cert. # ___________ issued at __________
issued on_____________________________________

Approved By___________________________________________________________
(Printed Name and Signature)

DEAN, PRC I.D. No. ___________________ Valid Until: ______________ _______


Date document is signed: ________________ Time: _________________________
Please specify Highest Nursing Degree Earned:_________________________________

ARRIESGADO COLLEGE FOUNDATION INC.

ODC FORM 2A
O.R. SCRUB FORM
Major

COLLEGE OF NURSING
201 Bonifacio Street, Tagum City
Email:vincentarriesgado@yahoo.com.ph
Tel. No. (084) 655-6583, (084) 655-6641

SURGICAL CIRCULATING: Southern Philippines Medical Center, JP laurel Ave, Bajada, Davao City, Davao del Sur__
Hospital, Municipality/City/Province
Prepared by: ________DAISY ANN RADA IIGO___________
Printed Name and Signature of Students

Date Performed and Time Started


Patients INITIAL only
Case Number
August 06,2012
05:59pm

C.R.
1589510

September 24, 2012


10:58am

C.M.L.
2103440

October 02, 2012


12:26pm

L.H.L.
2438625

SURGICAL PROCEDURE
PERFORMED
Repeat Low Segment Transverse
Caesarean Section with Bilateral
Tubal Ligation
Extract Capsular Cataract Extraction
with Insertion of Intra Ocular Lens
Right Eye by Small Incision
Cataract Surgery

Noted by__________________________________________________________________
(Print Name and Signature)

CLINICAL COORDINATOR, PRC I.D. No._____________ Valid Until: __________


Date document is signed: _____________________ Time: ________________________
Please specify Highest Nursing Degree Earned: __________________________________

Subscribed and sworn before me this _____ day ______________ of 2012 affiant
Exhibits to me his/her Community Tax Cert. # ___________ issued at __________
issued on_____________________________________

Split Thickness Skin Grafting

O.R. Nurse on Duty


(Name and Signature)

Supervised by:
Clinical Instructor
Name and Signature

Jose Luis Antonio S. Calatrava, RN


Lic. No. 0432899

Vinilo Hermoso, RN
Lic. No. 0391870

Maria J. Cardillo, RN

Miriam B. Lilio, RN, MAN


Lic. No. 0324014

Jose Mari . Velayo, RN


0559170

Miriam B. Lilio, RN, MAN


Lic. No. 0324014

Approved By___________________________________________________________
(Printed Name and Signature)

DEAN, PRC I.D. No. ___________________ Valid Until: ______________ _______


Date document is signed: ________________ Time: _________________________
Please specify Highest Nursing Degree Earned:_________________________________

ARRIESGADO COLLEGE FOUNDATION INC.


ODC FORM 2B O.R.
MINOR FORM

COLLEGE OF NURSING
201 Bonifacio Street, Tagum City
Email: Vincentarriesgado@yahoo.com.ph
Tel. No. (084) 217-3691, (084) 218-5328

SURGICAL SCRUB in: Southern Philippines Medical Center, JP laurel Ave, Bajada, Davao City, Davao del Sur__
Hospital, Municipality/City/Province
Prepared by: ________Daisy Ann Rada Iigo________
Printed Name and Signature of Students

Date Performed and Time


Started

Noted by:

Patients INITIAL only


Case Number

Catherine P. Cantalejo, RN, MAN_____________________


(Print Name and Signature)

CLINICAL COORDINATOR, PRC I.D. No._0243497


Valid Until: __________
Date document is signed: _____________________ Time: ________________________
Please specify Highest Nursing Degree Earned: __________________________________

Subscribed and sworn before me this _____ day ______________ of 2012 affiant
Exhibits to me his/her Community Tax Cert. # ___________ issued at __________
issued on_____________________________________

SURGICAL PROCEDURE
PERFORMED

Approved By:

O.R. Nurse on Duty


(Name and Signature)

Supervised by:
Clinical Instructor
Name and Signature

Joju Amor V. Denaque RN, MAN______________________


(Printed Name and Signature)

DEAN, PRC I.D. No. ___________________ Valid Until: ______________ _______


Date document is signed: ________________ Time: _________________________
Please specify Highest Nursing Degree Earned:_________________________________

ARRIESGADO COLLEGE FOUNDATION INC.

ODC FORM 2B
O.R. CIRCULATE FORM
Major

COLLEGE OF NURSING
201 Bonifacio Street, Tagum City
Email:vincentarriesgado@yahoo.com.ph
Tel. No. (084) 655-6583, (084) 655-6641

SURGICAL SCRUB in: Southern Philippines Medical Center, JP laurel Ave, Bajada, Davao City, Davao del Sur__
Hospital, Municipality/City/Province
Prepared by: ________DAISY ANN RADA IIGO________
Printed Name and Signature of Students

DATE PERFORMED AND TIME


STARTED

PATIENTS INITIAL ONLY


CASE NUMBER

SURGICAL PROCEDURE
PERFORMED

O.R. NURSE ON DUTY


(NAME AND SIGNATURE)

SUPERVISED BY:
CLINICAL INSTRUCTOR
NAME AND SIGNATURE

August 6, 2012
04:10pm

L.J.P.C.
2428092

Closed Reduction and Percutaneous


Pinning Left

Dagny C. Vijandre, RN
0490419

Vinilo Hermoso, RN
Lic. No. 0391870

August 6, 2012
08:00pm

A.J.A.
1016815

Caesarean Section with Bilateral


Tubal Ligation

Giovanni C. Chua, RN
0377162

Vinilo Hermoso, RN
Lic. No. 0391870

October 2, 2012
08:30qm

T.N.A.
1207752

Endoscopic Sinus Surgery

Lianne Marie B. Andales, RN


0669123

Miriam B. Lilio, RN, MAN


Lic. No. 0324014

Noted by__________________________________________________________________
(Print Name and Signature)

CLINICAL COORDINATOR, PRC I.D. No._____________ Valid Until: __________


Date document is signed: _____________________ Time: ________________________
Please specify Highest Nursing Degree Earned: __________________________________

Subscribed and sworn before me this _____ day ______________ of 2012 affiant
Exhibits to me his/her Community Tax Cert. # ___________ issued at __________
issued on_____________________________________

Approved By___________________________________________________________
(Printed Name and Signature)

DEAN, PRC I.D. No. ___________________ Valid Until: ______________ _______


Date document is signed: ________________ Time: _________________________
Please specify Highest Nursing Degree Earned:_________________________________