NURSING DEPARTMENT

551 MF Jhocson Street, Sampaloc Manila

Trunkline: 712-1900 Telefax: 749-8154 www.national-u.edu.ph

SURGICAL SCRUB in EAST AVENUE MEDICAL CENTER, QUEZON CITY

Hospital, Municipality/City/Province
Prepared by:
Print Name and Signature of Student HANAN M. EBRAHIM

Date Performed Patient’s INITIALS Only SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature
November 6, 2018 AB / Case # 0917068ERI Open Cholecystectomy Ms. Cherryl Mohammadnejad,
2:33 PM RN Ms. Mayo Santiago RN
JKB/Case #0971703 Debriment Irrigation malable
10:54 AM finger Jens Vergara, RN Ms. Mayo Santiago RN
November 14, 2018 PM / Case # 01974548 Open Reduction Crosspin Fixation
2:55 PM Supracon Left Mr. Jasper Quiambao, RN Ms. Mayo Santiago RN
CIRCULATING in EAST AVENUE MEDICAL CENTER, QUEZON CITY
Hospital, Municipality/City/Province
Prepared by: O.R Form 1B
Print Name and Signature of Student HANAN M. EBRAHIM O.R. CIRCULATING FORM
Major

Date Performed Patient’s INITIALS Only SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature
November 6, 2018 CBG / Case # 019771E0 Removal of tongue mass right
11:20 AM squamous cell carcinoma Ms. Mayo Santiago
March 7, 2019 RE / Case # 02018054 ER15 Bifrontal Craniotomy Excision of Mr. Diego Marcos Modico, RN
1:15 PM Tumor Ms. Mayo Santiago
November 7. 2018 RT / Case # 01971703 Below Knee Amputation
5:20 PM Mr. Jerald Rae Gabuya, RN Ms. Mayo Santiago RN
(STRICTLY NO DESIGNATES)
(These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)

D.R Form
ACTUAL
 NURSING DEPARTMENT
551 MF Jhocson Street, Sampaloc Manila
Trunkline: 712-1900 Telefax: 749-8154 www.national-u.edu.ph

ACTUAL DELIVERY in OSPITAL NG SAMPALOC DELIVERY FORM

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Print Name and Signature of Student HANAN M. EBRAHIM

Date Performed Patient’s INITIALS Only PROCEDURE O.R. Nurse On Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-in (If Midwife on Duty, signature not Name and Signature
Clinics/Homes) required)
March 18, 2019 MR/01956220 NORMAL SPONTANEOUS DELIVERY Filomena I. Juguilon, RN, MAN
7:50 PM
March 19, 2019 AR/01956245 NORMAL SPONTANEOUS DELIVERY Filomena I. Juguilon, RN, MAN
4:08 PM
March 20, 2019 ASM/01956277 NORMAL SPONTANEOUS DELIVERY Filomena I. Juguilon, RN, MAN
4:39 PM

IMMEDIATE NEWBORN CORD CARE in OSPITAL NG SAMPALOC

Hospital/Home/Lying-in Clinic, Municipality/City/Province ICNB Form
Prepared by: IMMEDIATE
Print Name and Signature of Student CARE OF THE
NEWBORN FORM

Date Performed Patient’s INITIALS Only Immediate Newborn Cord Care Nurse On Duty SUPERVISED BY
And Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-in Indicate where performed e.g. D.R.., (If Midwife on Duty, signature not Name and Signature
Clinics/Homes) Nursery, NICU, or Home required)
March 21, 2019 BBM/01956308 DELIVERY ROOM Filomena I. Juguilon, RN, MAN
7:00 PM
March 25, 2019 BBG/01956415 DELIVERY ROOM Filomena I. Juguilon, RN, MAN
6:34 PM
March 27, 2019 BGM/01956489 DELIVERY ROOM Filomena I. Juguilon, RN, MAN
 NURSING DEPARTMENT
551 MF Jhocson Street, Sampaloc Manila
Trunkline: 712-1900 Telefax: 749-8154 www.national-u.edu.ph

7:02 PM

(STRICTLY NO DESIGNATES)
(These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)