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Father Saturnino Urios University

(Formerly Urios College)


Butuan City

Name of Student: Leah Lou G. Montesclaros__________________________________________________________________________________________________________________________ __


Name & Address of School: Father Saturnino Urios University (Formerly Urios College)_______________________________________________________ ________________________________
Accreditation Level: II-PACUCOA____________________________________ Year Granted: May 3, 2004_______________________________________ ___________________________________
Date of School/Program was recognized: May 13, 1994_____________________ Number: 022________________________________________________ ______Year: 1994-1995___ ______________
First Course (if any): ________________________________________________ School Graduated From: ____________________________________ ________ Year: _____________ ____________
Year of Admission in the Bachelor of Science in Nursing Program: 2005__________________________________________________________________________________________________ ______
Year Graduated (BSN Program): 2009_____________________________________________________________________________________________ ___ ___________________________________

I. MAJOR OPERATIONS
No. Date of Case Name of Diagnosis Operation Performed Type of Name of Surgeon Name of Hospital Name of O.R. Scrub Signature of O.R.
Operation No. Patient Anesthesia Nurse Scrub Nurse
Elisa R. Ochoa
1. March 14, (Cens Diocina Breech Cesarean Section and Bilateral General Dr. Marilyn Maternity and General Mrs. Marites C.
2008 ored) Malibago Tubal Ligation Jumapao Hospital Miras, RN
Close fracture, Comminuted, Junction of
2. March 19, (Cens Gleceria Proximal and Middle third Humerus, Open Reduction - Plating General Dr. Ferdinand Manuel J. Santos Ms. Marilou M.
2008 ored) Fuentes Right Amante Hospital Villareal, RN

3. March 27, (Cens Rolando Acute Appendicitis, Ruptured Appendectomy, Lavage General Dr. Edecio Urag Manuel J. Santos Ms. Marilou M.
2008 ored) Yu Hospital Villareal, RN
Extra Capsular Cataract
4. October 16, (Cens Lilibeth Mature Cataract, Right Eye Extraction at Right Eye with Retrobulbar Dr. Reynaldo Manuel J. Santos Ms. Dyan Etheyl B.
2008 ored) Rebotazzo Intra Occular Lens Villanueva Hospital Hernandez, RN
Implantation
Enbloc Excision of Mass at
5. October 24, (Cens Marcelina Giant Cutaneous Neurofibrous Solitary Left Leg Posterior 3rd and Split General Dr. Bienvenido Agusan del Norte Mr. Michael M.
2008 ored) Enoy Leg Posterior Third, Left Thickness Grafting Cabela Provincial Hospital Montante, RN

Prepared by: Supervised by: Noted by: Concurred by: Concurred by: Approved by:

Leah Lou G. Montesclaros Mrs. Virginia A. Demata, RN, MAN Mrs. Mary Ann D. Bamba, RN Mrs. Jemimah L. Bringas, RN, MN Mrs. Helen T. Gonzales, RN, MN Mrs. Susan A. Mones, RN, MAN
Name of Student Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Dean of Nursing Department
Date Signed: __ Date Signed: Date Signed: __________________ Date Signed: Date Signed: ________________
Degree: BSN, RN, MAN _ Degree: BSN, RN____ Degree: _ BSN, RN, MN________ Degree: BSN, RN, MN Degree: BSN, RN, MAN ___
a.) PRC No.: 0113580 _ a.) PRC No.: 0348629 a.) PRC No.: _0089396__________ a.) PRC No.: 0063678 a.) PRC No.: 0120756_________
Valid Until: _NOV. 25, 2010_ _ Valid Until: _ FEB. 12, 2009_____ Valid Until: _MAY 19, 2008______ Valid Until: _AUG. 28, 2009 _____ Valid Until: _APR. 22, 2008 __
b.) PNA No.: _4673________ _ b.) PNA No.: 33957 b.) PNA No.: _33952____________ b.) PNA No.: _2504_____________ b.) PNA No.: _10640__________
Valid Until: _Lifetime_____ _ Valid Until: _ DEC. 2007________ Valid Until: _DEC. 2007_________ Valid Until: _Lifetime___________ Valid Until: _Lifetime_________
c.) ANSAP No.: _016439______ c.) ORNAP No.: _060027________ c.) ANSAP No.: _01834_________ c.) ANSAP No.: _01832__________ c.) ADPCN No.: _0593________
Valid Until: _ DEC. 2007______ Valid Until: _JULY 2008________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_______

I declared under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief in true, correct and complete statement pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of
the Philippines.
_____________________________
Signature of Applicant
Subscribed and sworn to before me this _________________ day of _________ 20____, _________________________________________ Philippines.

NOTARY PUBLIC
Father Saturnino Urios University
(Formerly Urios College)
Butuan City

Name of Student: Leah Lou G. Montesclaros___________________________________________________________________________________________________________________________ __


Name & Address of School: Father Saturnino Urios University (Formerly Urios College)_______________________________________________________ ________________________________
Accreditation Level: II-PACUCOA____________________________________ Year Granted: May 3, 2004_______________________________________ ___________________________________
Date of School/Program was recognized: May 13, 1994_____________________ Number: 022________________________________________________ ______Year: 1994-1995___ ______________
First Course (if any): ________________________________________________ School Graduated From: ____________________________________ ________ Year: _____________ ____________
Year of Admission in the Bachelor of Science in Nursing Program: 2005__________________________________________________________________________________________________ ______
Year Graduated (BSN Program): 2009_____________________________________________________________________________________________ ___ ___________________________________

II. MINOR OPERATIONS


No. Date of Case No. Name of Diagnosis Operation Performed Type of Name of Surgeon Name of Hospital Name of O.R. Scrub Nurse Signature of
Operation Patient Anesthesia O.R. Scrub
Nurse
Stab Wound, V-shaped, 4cm
1. October 1, (Censored) Arnel Level of 5th-6th Ribs, Parenteral Close Tube Thoracostomy Local Dr. Andre Malbas Butuan Medical Ms. Cristeta B. Butcon, RN
2007 Camique Area, Right Center
Elisa R. Ochoa
2. January 4, (Censored) Ernesto Sebaceous Cyst 3cm, Nose Excision Local Dr. Bayani Quinte Maternity and Ms. Jennyvev Sabellano, RN
2008 Tampus General Hospital

3. April 1, (Censored) Raynilda Abortion Incomplete Dilatation and Curettage General Dr. Gina Bacol Agusan Del Norte Mrs. Faith M. Dumoran, RN
2008 Cabcad Provincial Hospital
Intramuscular Pin In Situ– Removal of Pin at Left
4. April 1, (Censored) Alger Healed Proximal Distal 3rd Forearm and Bivalve Cast Dr. Bienvenido Cabela Agusan Del Norte Mrs. Loreta P. Ventura, RN,
2008 Galope Ulna–10 Months, Left Forearm Application Provincial Hospital MAN, MPSM, DODT
Elisa R. Ochoa
5. October 31, (Censored) Neil Lumor Lacerated Wound at Foot, Debridement and Suturing of Local Dr. Lynde Layese Maternity and Ms. Bernadette Enriquez,
2008 Right Wound at Right Foot General Hospital RN

Prepared by: Supervised by: Noted by: Concurred by: Approved by:

Leah Lou G. Montesclaros Mrs. Virginia A. Demata, RN, MAN Mrs. Mary Ann D. Bamba, RN Mrs. Jemimah L. Bringas, RN, MN Mrs. Susan A. Mones, RN, MAN
Name of Student Signature over printed name of Faculty Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Dean of Nursing Department
Date Signed: ______ Date Signed: Date Signed: __________________ Date Signed: __________________
Degree: BSN, RN, MAN ____ Degree: BSN, RN____ Degree: _ BSN, RN, MN________ Degree: BSN, RN, MAN
a.) PRC No.: 0113580 _ ____ a.) PRC No.: 0348629 a.) PRC No.: _0089396__________ a.) PRC No.: 0120756
Valid Until: _NOV. 25, 2010_ _____ Valid Until: _ FEB. 12, 2009_____ Valid Until: _MAY 19, 2008______ Valid Until: _APR. 22, 2008 ___
b.) PNA No.: _4673________ _____ b.) PNA No.: 33957 b.) PNA No.: _33952____________ b.) PNA No.: _10640____________
Valid Until: _Lifetime_____ _____ Valid Until: _ DEC. 2007________ Valid Until: _DEC. 2007_________ Valid Until: _Lifetime___________
c.) ANSAP No.: _016439__________ c.) ORNAP No.: _060027________ c.) ANSAP No.: _01834_________ c.) ADPCN No.: _0593__________
Valid Until: _ DEC. 2007__________ Valid Until: _JULY 2008________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_________

I declared under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief in true, correct and complete statement pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of
the Philippines.
_____________________________
Signature of Applicant
Subscribed and sworn to before me this _________________ day of _________ 20____, _________________________________________ Philippines.

NOTARY PUBLIC
Father Saturnino Urios University
(Formerly Urios College)
Butuan City

Name of Student: Leah Lou G. Montesclaros___________________________________________________________________________________________________________________________ __


Name & Address of School: Father Saturnino Urios University (Formerly Urios College)_______________________________________________________ ________________________________
Accreditation Level: II-PACUCOA____________________________________ Year Granted: May 3, 2004_______________________________________ ___________________________________
Date of School/Program was recognized: May 13, 1994_____________________ Number: 022________________________________________________ ______Year: 1994-1995___ ______________
First Course (if any): ________________________________________________ School Graduated From: ____________________________________ ________ Year: _____________ ____________
Year of Admission in the Bachelor of Science in Nursing Program: 2005__________________________________________________________________________________________________ ______
Year Graduated (BSN Program): 2009_____________________________________________________________________________________________ ___ ___________________________________

III. ACTUAL DELIVERIES


No. Case No. Diagnosis Name of Age Date of Time of Gender of Name of Hospital Type of Delivery Supervised By: Name and Signature of
Mother Delivery Delivery Baby Qualified Clinical Instructor
Pregnancy Uterine Pre Term, Normal Spontaneous
1. (Censored) 38 weeks Gestation Daisy 27 years September 25, 8:30 p.m. Female Butuan Medical Center Vaginal Delivery with
Gravida 3 Para 3 Gorgonio old 2007 Laceration and Repair
Pregnancy Uterine Full Term, Normal Spontaneous
2. (Censored) 39 weeks Gestation Merlyn 18 years October 24, 8:17 a.m. Female Agusan Del Norte Vaginal Delivery with
Gravida 1 Para 1 Castino old 2008 Provincial Hospital Episiotomy and Repair
Pregnancy Uterine Full Term, Elisa R. Ochoa Normal Spontaneous
3. (Censored) 39 weeks Gestation Teresita 37 years October 29, 2:19 p.m. Male Maternity and General Vaginal Delivery with
Gravida 3 Para 3 Lagahid old 2008 Hospital Episiotomy and Repair
Pregnancy Uterine Pre Term, Angel Mae Elisa R. Ochoa Normal Spontaneous
4. (Censored) 20 weeks Gestation Dumay 17 years October 31, 4:16 a.m. Female Maternity and General Vaginal Delivery
Gravida 1 Para 0 Ambray old 2008 Hospital (Stillbirth)
Pregnancy Uterine Full Term, Normal Spontaneous
5. (Censored) 39 weeks Gestation Rosalie 35 years March 9, 1:23 a.m. Female Butuan Medical Center Vaginal Delivery with
Gravida 3 Para 3 Amante old 2009 Laceration and Repair

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

Leah Lou G. Montesclaros Mrs. Mary Ann D. Bamba, RN Mrs. Jemimah L. Bringas, RN, MN Mrs. Helen T. Gonzales, RN, MN Mrs. Susan A. Mones, RN, MAN
Name of Student Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Dean of Nursing Department
Date Signed: Date Signed: __________________ Date Signed: Date Signed: ________________
Degree: BSN, RN____ Degree: _ BSN, RN, MN________ Degree: BSN, RN, MN _____ Degree: BSN, RN, MAN______
a.) PRC No.: 0348629 a.) PRC No.: _0089396__________ a.) PRC No.: 0063678 a.) PRC No.: 0120756_________
Valid Until: _ FEB. 12, 2009_____ Valid Until: _MAY 19, 2008______ Valid Until: _AUG. 28, 2009 _____ Valid Until: _APR. 22, 2008 _
b.) PNA No.: 33957 b.) PNA No.: _33952____________ b.) PNA No.: _2504_____________ b.) PNA No.: _10640__________
Valid Until: _ DEC. 2007________ Valid Until: _DEC. 2007_________ Valid Until: _Lifetime___________ Valid Until: _Lifetime_________
c.) ORNAP No.: _060027________ c.) ANSAP No.: _01834_________ c.) ANSAP No.: _01832__________ c.) ADPCN No.: _0593________
Valid Until: _JULY 2008________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_______

I declared under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief in true, correct and complete statement pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of
the Philippines.
_____________________________
Signature of Applicant
Subscribed and sworn to before me this _________________ day of _________ 20____, _________________________________________ Philippines.

NOTARY PUBLIC
Father Saturnino Urios University
(Formerly Urios College)
Butuan City

Name of Student: Leah Lou G. Montesclaros__________________________________________________________________________________________________________________________ __


Name & Address of School: Father Saturnino Urios University (Formerly Urios College)_______________________________________________________ ________________________________
Accreditation Level: II-PACUCOA____________________________________ Year Granted: May 3, 2004_______________________________________ ___________________________________
Date of School/Program was recognized: May 13, 1994_____________________ Number: 022________________________________________________ ______Year: 1994-1995___ ______________
First Course (if any): ________________________________________________ School Graduated From: ____________________________________ ________ Year: _____________ ____________
Year of Admission in the Bachelor of Science in Nursing Program: 2005__________________________________________________________________________________________________ ______
Year Graduated (BSN Program): 2009_____________________________________________________________________________________________ ___ ___________________________________

IV. DELIVERIES ASSISTED


No. Case No. Diagnosis Name of Age Date of Time of Gender of Name of Hospital Type of Delivery Supervised By: Name and Signature of
Mother Delivery Delivery Baby Qualified Clinical Instructor
Pregnancy Uterine Full Term, Normal Spontaneous Vaginal
1. (Censored) 39 weeks Gestation Mary Joy 27 years September 24, 10:07 p.m. Male Butuan Medical Center Delivery with Episiotomy and
Gravida 3 Para 3 Quipanes old 2007 Repair
Pregnancy Uterine Full Term,
2. (Censored) 41 weeks Gestation Fraida 31 years October 1, 8:13 p.m. Female Butuan Medical Center Normal Spontaneous Vaginal
Gravida 5 Para 5 Pequit old 2007 Delivery
Pregnancy Uterine Full Term, Normal Spontaneous Vaginal
3. (Censored) 40 weeks Gestation Novelyn 28 years March 14, 6:20 p.m. Female Agusan Del Norte Delivery with Laceration and
Gravida 3 Para 2 Tutor old 2008 Provincial Hospital Repair
Pregnancy Uterine Full Term, Jessa Normal Spontaneous Vaginal
4. (Censored) 40 weeks Gestation Nedrodu 22 years March 15, 5:02 p.m. Male Agusan Del Norte Delivery with Episiotomy and
Gravida 1 Para 1 Palen old 2008 Provincial Hospital Repair
Pregnancy Uterine Pre Term, Normal Spontaneous Vaginal
5. (Censored) 38 weeks Gestation Arlyn 19 years October 24, 8:36 a.m. Male Agusan Del Norte Delivery with Episiotomy and
Gravida 2 Para 2 Rosit old 2008 Provincial Hospital Repair

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

Leah Lou G. Montesclaros Mrs. Mary Ann D. Bamba, RN Mrs. Jemimah L. Bringas, RN, MN Mrs. Helen T. Gonzales, RN, MN Mrs. Susan A. Mones, RN, MAN
Name of Student Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Dean of Nursing Department
Date Signed: Date Signed: __________________ Date Signed: Date Signed: ________________
Degree: BSN, RN____ Degree: _ BSN, RN, MN________ Degree: BSN, RN, MN _____ Degree: BSN, RN, MAN______
a.) PRC No.: 0348629 a.) PRC No.: _0089396__________ a.) PRC No.: 0063678 a.) PRC No.: 0120756_________
Valid Until: _ FEB. 12, 2009_____ Valid Until: _MAY 19, 2008______ Valid Until: _AUG. 28, 2009 _____ Valid Until: _APR. 22, 2008 __
b.) PNA No.: 33957 b.) PNA No.: _33952____________ b.) PNA No.: _2504_____________ b.) PNA No.: _10640__________
Valid Until: _ DEC. 2007________ Valid Until: _DEC. 2007_________ Valid Until: _Lifetime___________ Valid Until: _Lifetime_________
c.) ORNAP No.: _060027________ c.) ANSAP No.: _01834_________ c.) ANSAP No.: _01832__________ c.) ADPCN No.: _0593________
Valid Until: _JULY 2008________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_______

I declared under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief in true, correct and complete statement pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of
the Philippines.
_____________________________
Signature of Applicant
Subscribed and sworn to before me this _________________ day of _________ 20____, _________________________________________ Philippines.

NOTARY PUBLIC
Father Saturnino Urios University
(Formerly Urios College)
Butuan City

Name of Student: Leah Lou G. Montesclaros___________________________________________________________________________________________________________________________ __


Name & Address of School: Father Saturnino Urios University (Formerly Urios College)_______________________________________________________ ________________________________
Accreditation Level: II-PACUCOA____________________________________ Year Granted: May 3, 2004_______________________________________ ___________________________________
Date of School/Program was recognized: May 13, 1994_____________________ Number: 022________________________________________________ ______Year: 1994-1995___ ______________
First Course (if any): ________________________________________________ School Graduated From: ____________________________________ ________ Year: _____________ ____________
Year of Admission in the Bachelor of Science in Nursing Program: 2005__________________________________________________________________________________________________ ______
Year Graduated (BSN Program): 2009_____________________________________________________________________________________________ ___ ___________________________________

V. CORD DRESSING
No. Case No. Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital Supervised By: Name and Signature of Qualified
Clinical Instructor

1. (Censored) September 24, 2007 Baby Dela Cruz Female Vilma Dela Cruz 31 years old Butuan Medical Center

2. (Censored) October 3, 2007 Baby Orebia Female Jennifer Orebia 23 years old Butuan Medical Center

3. (Censored) March 15, 2008 Baby Calayca Male Vivian Calayca 33 years old Agusan Del Norte Provincial
Hospital

4. (Censored) March 15, 2008 Baby Agcang Male Analia Agcang 23 years old Agusan Del Norte Provincial
Hospital

5. (Censored) February 28, 2009 Baby Romero Male Rosaly Romero 23 years old Butuan Medical Center

Prepared by: Noted by: Concurred by: Concurred by: Approved by:

Leah Lou G. Montesclaros Mrs. Mary Ann D. Bamba, RN Mrs. Jemimah L. Bringas, RN, MN Mrs. Helen T. Gonzales, RN, MN Mrs. Susan A. Mones, RN, MAN
Name of Student
Signature over printed name of Clinical Coordinator Signature over printed name of Chief Nurse Signature over printed name of Chief Nurse Dean of Nursing Department
Date Signed: Date Signed: __________________ Date Signed: Date Signed: ________________
Degree: BSN, RN____ Degree: _ BSN, RN, MN________ Degree: BSN, RN, MN _____ Degree: BSN, RN, MAN______
a.) PRC No.: 0348629 a.) PRC No.: _0089396__________ a.) PRC No.: 0063678 a.) PRC No.: 0120756_________
Valid Until: _ FEB. 12, 2009_____ Valid Until: _MAY 19, 2008______ Valid Until: _AUG. 28, 2009 _____ Valid Until: _APR. 22, 2008 __
b.) PNA No.: 33957 b.) PNA No.: _33952____________ b.) PNA No.: _2504_____________ b.) PNA No.: _10640__________
Valid Until: _ DEC. 2007________ Valid Until: _DEC. 2007_________ Valid Until: _Lifetime___________ Valid Until: _Lifetime_________
c.) ORNAP No.: _060027________ c.) ANSAP No.: _01834_________ c.) ANSAP No.: _01832__________ c.) ADPCN No.: _0593________
Valid Until: _JULY 2008________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_________ Valid Until: _DEC. 2007_______

I declared under oath that these cases had been accomplished by me in good faith, verified by me and to the best of my knowledge and belief in true, correct and complete statement pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of
the Philippines.
_____________________________
Signature of Applicant
Subscribed and sworn to before me this _________________ day of _________ 20____, _________________________________________ Philippines.

NOTARY PUBLIC