LYCEUM-NORTHWESTERN UNIVERSITY

Tapuac District, Dagupan City

(075) 516-2429/ Fax No. (63) (75) 516-2434
Email: info@lyceum.edu.ph/www.lyceum.edu.ph

ACTUAL DELIVERY in PANGASINAN PROVINCIAL HOSPITAL, San Carlos City, Pangasinan

Hospital, Municipality/City/Province
Prepared by:
D.R. Form
(Printed Name with Signature of Student) : MUMTA KHAMB ACTUAL DELIVERY
FORM
Date Performed Patients INITIALS (only)
and D.R. Nurse On Duty
Case Number SUPERVISED BY
Time Started (Name and Signature)
(Not applicable for PROCEDURE PERFORMED (If Midwife on Duty,
Clinical Instructor
Birthing/Lying-In (Name and Signature)
Signature not Required)
Clinics/Home)
August 13, 2015 L.dG.
1:18 A.M. #009188 NORMAL SPONTANEOUS Marie Joy V. Manuel, Czarina Anne D. Posadas, RN
August 26, 2015 R.C. DELIVERY RN MAN,PhD
2:48 A.M. #012294 NORMAL SPONTANEOUS Jhona S. Austria, RN Czarina Anne D. Posadas, RN
August 26, 2015 V.L. DELIVERY MAN,PhD
7:00 A.M. #012442 NORMAL SPONTANEOUS Jhona S. Austria, RN Czarina Anne D. Posadas, RN
August 26, 2015 R.dG. DELIVERY MAN,PhD
11:35 P.M. #293598 NORMAL SPONTANEOUS Jhona S. Austria, RN Czarina Anne D. Posadas, RN
September 2, 2015 J.M.B. DELIVERY MAN,PhD
5:30 P.M. #014026 NORMAL SPONTANEOUS Jhona S. Austria, RN Czarina Anne D. Posadas, RN
DELIVERY MAN,PhD
Noted by: HILDA V. CRUZ Approved by: JUDITH M. MANUEL
Clinical Coordinator College Dean
PRC I.D. No. __0321370 Valid Until: October 29, 2018 PRC I.D. No. 0104865_ Valid Until:
August 01, 2016
Date document is signed: ______________ Time: ______________________ Date document is signed: _________ Time:
____________________
Highest Nursing Degree Earned: BSN, R.N., M.A.N. Highest Nursing Degree Earned: BSN, R.N.,
M.A.N.

LYCEUM-NORTHWESTERN UNIVERSITY
Tapuac District, Dagupan City
(075) 516-2429/ Fax No. (63) (75) 516-2434
Email: info@lyceum.edu.ph/www.lyceum.edu.ph

IMMEDIATE NEWBORN CORD CARE in PANGASINAN PROVINCIAL HOSPITAL, San Carlos City, Pangasinan
Hospital, Municipality/City/Province
Prepared by: ICNB Form
IMMEDIATE CARE OF
THE
(Printed Name with Signature of Student) : MUMTA KHAMB
NEWBORN FORM
Date
Patients INITIALS (only) Nurse On Duty
Performed Immediate Newborn Cord Care
(Name and Signature) SUPERVISED BY
and Case Number PERFORMED (If Midwife on Duty, Clinical Instructor
Time Started (Not applicable for Indicate where performed e.g. Signature not (Name and Signature)
Birthing/Lying-In D.R.,Nursery, NICU, or Home Required)
Clinics/Home)
August 12, B.B.P.
2015 #009129 DELIVERY ROOM Emmalyn P. Bulatao, Czarina Anne D. Posadas, RN
3:56 A.M. RN MAN,PhD
August 26, B.B.T.
2015 #012440 DELIVERY ROOM Hyacinth Joy A. Czarina Anne D. Posadas, RN
1:36 A.M. Rosario, RN MAN,PhD
August 26, B.G.U.
2015 #012458 DELIVERY ROOM Hyacinth Joy A. Czarina Anne D. Posadas, RN
6:01 A.M. Rosario, RN MAN,PhD
August 27, B.B.B.
2015 #012684 DELIVERY ROOM Aldrich Karl S. Czarina Anne D. Posadas, RN
5:41 A.M. Camero, RN MAN,PhD
Noted by: HILDA V. CRUZ Approved by: JUDITH M. MANUEL
 Clinical Coordinator College Dean
PRC I.D. No. __0321370 Valid Until: October 29, 2018 PRC I.D. No. 0104865_ Valid Until:
August 01, 2016
Date document is signed: ______________ Time: ______________________ Date document is signed: _________ Time:
____________________
Highest Nursing Degree Earned: BSN, R.N., M.A.N. Highest Nursing Degree Earned: BSN, R.N.,
M.A.N.

LYCEUM-NORTHWESTERN UNIVERSITY
Tapuac District, Dagupan City
(075) 516-2429/ Fax No. (63) (75) 516-2434
Email: info@lyceum.edu.ph/www.lyceum.edu.ph

IMMEDIATE NEWBORN CORD CARE in BAYAMBANG DISTRICT HOSPITAL, Bayambang, Pangasinan

Hospital, Municipality/City/Province
Prepared by: ICNB Form
IMMEDIATE CARE OF
THE
(Printed Name with Signature of Student) : MUMTA KHAMB
NEWBORN FORM
Date Performed
Patients INITIALS (only)
and Immediate Newborn Cord Care Nurse On Duty
SUPERVISED BY
Time Started Case Number PERFORMED (Name and Signature)
Clinical Instructor
(Not applicable for Indicate where performed e.g. (If Midwife on Duty,
(Name and Signature)
Birthing/Lying-In D.R.,Nursery, NICU, or Home Signature not Required)
Clinics/Home)
September 10, B.G.A.
2015 #148926 DELIVERY ROOM Abcde A. Fausto, RN Delia R. Escao, RN, MAN
7:23 A.M.

Noted by: HILDA V. CRUZ Approved by: JUDITH M. MANUEL

Clinical Coordinator College Dean
PRC I.D. No. __0321370 Valid Until: October 29, 2018 PRC I.D. No. 0104865_ Valid Until:
August 01, 2016
Date document is signed: ______________ Time: ______________________ Date document is signed: _________ Time:
____________________
Highest Nursing Degree Earned: BSN, R.N., M.A.N. Highest Nursing Degree Earned: BSN, R.N.,
M.A.N.