UNIVERSITY of PANGASINAN

PHINMA EDUCATION NETWORK University Seal

COLLEGE OF NURSING
Arellano St. Dagupan City

Phone No. (075)522-5635-37; Fax No. (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Date School/Program was recognized: May 19, 1976; Number 44; Year: 1976)
(Level I PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB IN REGION I MEDICAL CENTER/DAGUPAN CITY, PANGASINAN ___________

Hospital/Home/Lying-in Clinic/Municipality/City/Province

O.R Form 1B
O.R CIRCULATING FORM
Prepared by: Major
Printed Name with Signature of Student: TUBIL, CENNA LYNNE Bolaton___________ ________________ _________

Date Performed Patient’s INITIAL only O.R. NURSE ON DUTY Supervised by:
And PROCEDURE PERFORMED (Name) CLINICAL INSTRUCTOR
Time Started (Name and Signature)
Case Number

April 08, 2019 L.F.L Low Transverse Caesarean Section I with Bilateral Tubal Alica L. Viloria,RN Floro C. Carreon Jr.,RN,MAN
01:26PM Ligation
644157

April 09, 2019 A.M.T Pelvic Laparotomy Total Abdominal Hysterectomy with Rachel Ann Inocencio,RN Floro C. Carreon Jr.,RN,MAN
10:25AM Bilateral Salpingo- Oophorectomy
637320
T.D.S
April 10, 2019
Open Cholecystectomy Rachel Ann Inocencio,RN Floro C. Carreon Jr.,RN,MAN
11:15AM
131431

Noted by: LIZA D. FUCANAN __ Approved by: MARIA TERESA R. FAJARDO_______________

Clinical Coordinator College Dean

PRC I.D No. 0108608 _______Valid Until: January 01, 2020 PRC I.D No. 0160104 Valid Until: September 09, 2019__
Date document is signed:______________ Time:__________________ Date document is signed: ______Time:________________________
Please Specify Degree Earned: RN, MAN___________________ __ _ Please Specify Degree Earned: RN, MAN, Ed.D _____________________________