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UNIVERSITY OF PANGASINAN Name of Patient: Name of Patient:

PHINMA Education Network ____________________________________________________ ____________________________________________________
College of Nursing Case No.: ________________ Gender: ____________________ Case No.: ________________ Gender: ____________________
Dagupan City Name of Mother: Name of Mother:
____________________________________________________ ____________________________________________________
CORD CASE SLIP Address: ____________________________________________ Address: ____________________________________________
Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Time of Delivery: _____________________________________ Time of Delivery: _____________________________________
Name of Student Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Pediatrician: _________________________________________ Pediatrician: _________________________________________
___________________________
Student Number _________________________ _____________________ _________________________ _____________________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor

PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN _________________________ _____________________ _________________________ _____________________

Clinical Coordinator PRC No. PRC No. PRC No. PRC No.

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

Agency: Agency:
PNA NO: .VALID UNTIL: .
____________________________________________________ ____________________________________________________
ANSAP NO: .VALID UNTIL: .

Name of Patient:
____________________________________________________
Case No.: ________________ Gender: ____________________
Name of Mother:
____________________________________________________
Address: ____________________________________________
Date of Delivery: _____________________________________
Gender of Baby: ______________________________________
Time of Delivery: _____________________________________
Type of Delivery: _____________________________________
Pediatrician: _________________________________________
354
Name of Patient:
____________________________________________________
Case No.: ________________ Gender: ____________________
Name of Mother:
____________________________________________________
Address: ____________________________________________
Date of Delivery: ______________________________________
Gender of Baby: _______________________________________
Time of Delivery: _____________________________________
Type of Delivery: ______________________________________
Pediatrician: _________________________________________
Name of Patient:
____________________________________________________
Case No.: ________________ Gender: ____________________
Name of Mother:
____________________________________________________
Address: ____________________________________________
Date of Delivery: _____________________________________
Gender of Baby: ______________________________________
Time of Delivery: _____________________________________
Type of Delivery: _____________________________________
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: Agency: Agency:

____________________________________________________ ____________________________________________________ ____________________________________________________