ARELLANO UNIVERSITY ODC Form 2A

COLLEGE of NURSING O.R. SCRUB MAJOR FORM

2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) in _______ARELLANO UNIVERSITY MEDICAL CENTER, Manila, Metro Manila_______________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student _ JUAN A. DELA CRUZ__________________________

Date Performed Patient’s INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical instructor
Time Started Case Number Name and Signature

March 05, 2007 K. B. P.

9:00 AM 11436 Herniotomy Bilateral Maria Teresa Alvarez R.N. Maria Cristina Falls, R.N., MAN
April 24, 2007 C. A. G. Phacoemulsification with
2:00 PM 0407000447 Intra Ocular Lens left Eumel Martin Geronimo R.N. Britney S. Peers, R.N., MSN, Ed.D
April 26, 2007 L. D. C. Craniotomy Reopen, Evacuation
8:00 AM 0407000416 of Blood Clots, Ligation of Maria Teresa Alvarez R.N. Jun Cary V. Suitos, R.N., MAN, CNS, Ph. D
Bleeders
August 30, 2007 P. V. Z. Emergency Appendectomy with
9:30 AM 3473 Exploratory Laparotomy Eumel Martin Geronimo R.N. Rachelle Ann Ligan R.N., MAN
September 05, 2007 C. P. R.
4:00 PM 3532 Cholecystectomy Maria Teresa Alvarez R.N. Jonil P. Dalisay R.N., MAN

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 2B
COLLEGE of NURSING O.R. SCRUB MINOR FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Minor) in ____________SAN LEONARDO HOSPITAL , Pasig City, Metro Manila, ________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student _ JUAN A. DELA CRUZ__________________________

Date Performed Patient’s INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical instructor
Time Started Case Number Name and Signature

March 05, 2007 J. M.M.

9:00 AM 19768 Suturing Jonil Dalisay R.N. Dalisay Mawari R.N., MAN
April 24, 2007 D. L. P.
2:00 PM 0407000466 Excision of Pterygium Jonil Dalisay R.N. Eumel Martin Geronimo R.N., MAN
April 26, 2007 F. S. D. Proctosigmoidoscopy,
8:00 AM 3498 Wound Debridement, Fistulotomy Jonil Dalisay R.N. Eumel Martin Geronimo R.N., MAN
August 30, 2007 W. O. L.
9:30 AM 3468 Excision Biopsy of Sebaceous cyst Maria Kathleen Renos R.N. Maria Teresa Alvarez R.N., MAN
September 05, 2007 R. R. R.
4:00 PM 371093 Completion Curettage Maria Kathleen Renos R.N. Maria Teresa Alvarez R.N., MAN

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 1A
COLLEGE of NURSING ACTUAL DELIVERY FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ACTUAL DELIVERY in ___________OAKWOOD GENERAL HOSPITAL , Antipolo City, Rizal ____________

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student _ JUAN A. DELA CRUZ______________________

Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty (Name and Signature) SUPERVISED BY
and PERFORMED (If Midwife on Duty, Signature Not Required) Clinical instructor
Time Started Case Number Name and Signature
(not applicable for Birthing/Lying-
in Clinic/Home)
August 28, 2007 A.F.A.
5:12 PM 4408 Normal Spontaneous Delivery Rachelle Ann Ligan R.N. Maria Kathleen Renos R.N., MAN
January 12, 2008 J.G.D.
2:12 PM 317847 Normal Spontaneous Delivery Rachelle Ann Ligan R.N. Maria Kathleen Renos R.N., MAN
January 13, 2008 S.C.C.
5:08 PM 517748 Normal Spontaneous Delivery Rachelle Ann Ligan R.N. Maria Kathleen Renos R.N., MAN
January 13, 2008 A.T.P.
5:57 PM 517749 Normal Spontaneous Delivery Iris Villamor R.N. Eumel Martin Geronimo R.N., MAN
January 13, 2008 A.M.R.
8:48 PM 517750 Normal Spontaneous Delivery Iris Villamor R.N. Eumel Martin Geronimo R.N., MAN

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 1B
COLLEGE of NURSING ASSISTED DELIVERY FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ASSISTED DELIVERY in ________ ALWAYS OPEN LYING IN CLINIC, Quezon City, Metro Manila_ _______
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student _ JUAN A. DELA CRUZ_______________________

Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty (Name and Signature) SUPERVISED BY
and PERFORMED (If Midwife on Duty, Signature Not Required) Clinical instructor
Time Started Case Number Name and Signature
(not applicable for Birthing/Lying- ASSISTED DELIVERY
in Clinic/Home)
August 21, 2007 A.P.A.
4:04 AM 4403 Normal Spontaneous Delivery Maria Teresa Alvarez R.N. Justin Bieber R.N., MAN
August 26, 2007 A.A.S.
4:15 PM 4405 Normal Spontaneous Delivery Maria Teresa Alvarez R.N. Iris Villamor R.N., MAN
January 13, 2008 J.A.R.
5:08 PM 431127 Normal Spontaneous Delivery Maria Teresa Alvarez R.N. Santino Batingting R.N., MAN
January 13, 2008 J.E.T.
5:57 PM 508437 Normal Spontaneous Delivery Jonil Dalisay R.M. Rachelle Ann Ligan R.N., MAN
January 13, 2008 M.R.D.
8:48 PM 517751 Normal Spontaneous Delivery Jonil Dalisay R.N. Makisig C. Sig R.N., MAN

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 1C
COLLEGE of NURSING CORD CARE FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

IMMEDIATE NEWBORN CORD CARE in ____________SAN MARCELINO HOSPITAL, Lipa City, Batanggas __________
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student _ JUAN A. DELA CRUZ_______________________

Date Performed Patient’s INITIAL Only Immediate Newborn Cord Care D.R. Nurse On Duty (Name and Signature) SUPERVISED BY
and PERFORMED (If Midwife on Duty, Signature Not Required) Clinical instructor
Time Started Case Number Indicate where performed e.g. D.R., Name and Signature
(not applicable for Birthing/Lying- Nursery, NICU, or Home
in Clinic/Home)
August 20, 2007 A.D.A.
4:00 PM 4400 Delivery Room Maria Kathleen Renos R.N. Iris Villamor R.N., MAN
August 20, 2007 A.P.S.
6:15 PM 4405 Delivery Room Maria Kathleen Renos R.N. Iris Villamor R.N., MAN
January 13, 2008 J.L.R.
6:15 PM 431127 Delivery Room Maria Kathleen Renos R.N. Mayumi Paraiso R.N., MAN
January 13, 2008 L.R.T.
7:30 PM 508437 NICU Jonil Dalisay R.N. Maria Teresa Alvarez R.N., MAN
January 13, 2008 M.R.T.
8:20 PM 517751 NICU Jonil Dalisay R.N. Maria Teresa Alvarez R.N., MAN

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN