University of Luzon

COLLEGE OF NURSING
Perez Boulevard, Dagupan City
Email: ulcn@ul.edu.ph
CP#: +63 943-702-5059 MAJOR SCRUB

NAME OF STUDENT: Curriculum Year:

Date: Case Number:

Name of Patient: Age: Sex:
Address:
Pre-Operative Diagnosis:
Time Started: Time Ended:
Post-Operative Diagnosis:
Operation Performed:
Type of Anesthesia/Time: Anesthesiologist:
Surgeon:
Name of Hospital:
Student Circulating Nurse:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Patient: Age: Sex:
Address:
Pre-Operative Diagnosis:
Time Started: Time Ended:
Post-Operative Diagnosis:
Operation Performed:
Type of Anesthesia/Time: Anesthesiologist:
Surgeon:
Name of Hospital:
Student Circulating Nurse:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Patient: Age: Sex:
Address:
Pre-Operative Diagnosis:
Time Started: Time Ended:
Post-Operative Diagnosis:
Operation Performed:
Type of Anesthesia/Time: Anesthesiologist:
Surgeon:
Name of Hospital:
Student Circulating Nurse:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

 University of Luzon
COLLEGE OF NURSING
Perez Boulevard, Dagupan City
Email: ulcn@ul.edu.ph
CP#: +63 943-702-5059
MAJOR CIRCULATING

NAME OF STUDENT: Curriculum Year:

Date: Case Number:

Name of Patient: Age: Sex:
Address:
Pre-Operative Diagnosis:
Time Started: Time Ended:
Post-Operative Diagnosis:
Operation Performed:
Type of Anesthesia/Time: Anesthesiologist:
Surgeon:
Name of Hospital:
Student Scrub Nurse:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Patient: Age: Sex:
Address:
Pre-Operative Diagnosis:
Time Started: Time Ended:
Post-Operative Diagnosis:
Operation Performed:
Type of Anesthesia/Time: Anesthesiologist:
Surgeon:
Name of Hospital:
Student Scrub Nurse:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Patient: Age: Sex:
Address:
Pre-Operative Diagnosis:
Time Started: Time Ended:
Post-Operative Diagnosis:
Operation Performed:
Type of Anesthesia/Time: Anesthesiologist:
Surgeon:
Name of Hospital:
Student Scrub Nurse:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

 University of Luzon
COLLEGE OF NURSING
Perez Boulevard, Dagupan City
Email: ulcn@ul.edu.ph
CP#: +63 943-702-5059
ACTUAL DELIVERY

NAME OF STUDENT: Curriculum Year:

Date: Case Number:

Name of Mother: Age:
Pre-Diagnosis:
Principal Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Student Assist: Cord Care done by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Mother: Age:
Pre-Diagnosis:
Principal Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Student Assist: Cord Care done by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Mother: Age:
Pre-Diagnosis:
Principal Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Student Assist: Cord Care done by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

 University of Luzon
COLLEGE OF NURSING
Perez Boulevard, Dagupan City
Email: ulcn@ul.edu.ph
CP#: +63 943-702-5059
ASSISTED DELIVERY

NAME OF STUDENT: Curriculum Year:

Date: Case Number:

Name of Mother: Age:
Pre-Diagnosis:
Principal Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Actual Delivery done by: Cord Care done by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Mother: Age:
Pre-Diagnosis:
Principal Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Actual Delivery done by: Cord Care done by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Mother: Age:
Pre-Diagnosis:
Principal Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Actual Delivery done by: Cord Care done by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

 University of Luzon
COLLEGE OF NURSING
Perez Boulevard, Dagupan City
Email: ulcn@ul.edu.ph
CP#: +63 943-702-5059 CORD CARE

NAME OF STUDENT: Curriculum Year:

Date: Case Number:

Name of Mother: Age:
Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Actual Delivery done by: Assisted by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Mother: Age:
Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Actual Delivery done by: Assisted by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

Date: Case Number:

Name of Mother: Age:
Diagnosis:
Time of Delivery:
Gender of the Baby:
Type of Delivery:
Name of Hospital:
Actual Delivery done by: Assisted by:

Name Staff Nurse on Duty/ Valid PRC Number Signature

Clinical Instructor/Valid PRC Number Signature

University of Luzon
COLLEGE OF NURSING
Perez Boulevard, Dagupan City
Email: ulcn@ul.edu.ph
CP#: +63 943-702-5059