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UNIVERSITY OF SAN CARLOS ODC Form 1A

COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES ACTUAL DELIVERY FORM
PHONE: 032 3433005; FAX 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph

PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

ACTUAL DELIVERY in Juan B. Dosado Memorial Hospital, Sugod, Cebu


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

Prepared by:

Printed Name with Signature of Student: JEZIEL JOY C. CORITICO

Patient’s INITIALS (only)


Case Number D.R. Nurse on Duty
Date Performed SUPERVISED BY
(not applicable for PROCEDURE PERFORMED (Name and Signature)
and Clinical Instructor
Birthing Home/Lying-in (if Midwife on duty, Signature
Time Started (Name and Signature)
Clinics/Names) Not Required)

November 23, J.S.B Khristle Ann C. Cañares, RN,


Actual Delivery Nanine G. Gomez, RN
2010 01-42-59 MAN
7:14 AM

Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN Approved by: ANTONIA F. PASCUAL, RN, MN,MSN
(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 Dean, PRC I.D. No. 0054229 Valid Until August 05,
2012

Date document is signed ________________________ Time _____ ________ Date document is signed________________ Time _______________

Please specify Highest Nursing Degree Earned Master of Science in Nursing Specify Highest Nursing Degree Earned Master in
Nursing_________

Master of Arts in Nursing____ Master of


Science in Nursing

(STRICTLY NO DESIGNATES)

UNIVERSITY OF SAN CARLOS ODC Form 1B


COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES ASSISTED DELIVERY
PHONE: 032 3433005; FAX 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph FORM
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

ACTUAL DELIVERY in Juan B. Dosado Memorial Hospital, Sugod, Cebu


Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:

Printed Name with Signature of Student: JEZIEL JOY C. CORITICO

Patient’s INITIALS (only)


Case Number O.R. Nurse on Duty
Date Performed SUPERVISED BY
(not applicable for PROCEDURE PERFORMED (Name and Signature)
and Clinical Instructor
Birthing Home/Lying-in (if Midwife on duty, Signature Not
Time Started (Name and Signature)
Clinics/Names) Required)

November 23,
J.R.V Khristle Ann C. Cañares, RN,
2010 .Assisted Delivery Maria February Lin Y. Matigas, RN
02-53-92 MAN
4:40 AM

Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN Approved by: ANTONIA F. PASCUAL, RN, MN,MSN

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 Dean, PRC I.D. No. 0054229 Valid Until August 05, 2012

Date document is signed ____________ _____ Time _____ _________ Date document is signed____________________ Time ___________

Please specify Highest Nursing Degree Earned Master of Science in Nursing Specify Highest Nursing Degree Earned Master in
Nursing__________ Master of Arts in Nursing
Master of Science in Nursing
(STRICTLY NO DESIGNATES)

UNIVERSITY OF SAN CARLOS ODC Form 1C


COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES CORD CARE FORM
PHONE: 032 3433005; FAX 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph

PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

IMMEDIATE NEWBORN CORD CARE in Juan B. Dosado Memorial Hospital, Sugod, Cebu
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:

Printed Name with Signature of Student: JEZIEL JOY C. CORITICO

Patient’s INITIALS (only)


Case Number IMMEDIATE NEWBORN CORD CARE O.R. Nurse on Duty
Date Performed SUPERVISED BY
(not applicable for PERFORMED (Name and Signature)
and Clinical Instructor
Birthing Home/Lying-in (Indicate where performed e.g. (if Midwife on duty, Signature
Time Started (Name and Signature)
Clinics/Names) D.R.,Nursery,NICU, or Home) Not Required)

November 21, B.G.V Khristle Ann C. Cañares, RN,


Delivery Room
2010 02-53-82 Nanine G. Gomez, RN MAN
1:25 AM
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN_ Approved by: ANTONIA F. PASCUAL, RN, MN,MSN _

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 Dean, PRC I.D. No. 0054229 Valid Until August 05,
2012

Date document is signed ______________________ Time ________________ Date document is signed ___________________ Time
_____________

Please specify Highest Nursing Degree Earned Master of Science in Nursing__ Specify Highest Nursing Degree Earned Master in
Nursing____________ Master of Arts in Nursing
Master of Science in Nursing__

(STRICTLY NO DESIGNATES)

UNIVERSITY OF SAN CARLOS ODC Form 2A


COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES O.R. SCRUB FORM
PHONE: 032 3433005; FAX 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph MAJOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
SURGICAL SCRUB in Vicente Sotto Memorial Medical Center_
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:

Printed Name with Signature of Student: Gracel R. Flores _

Patient’s INITIALS
Date Performed (only) SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
and (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

April 28, 2010 C.C.A Khristle Ann C.


Exploratory Laparatomy Emmylou D. Hermosa, RN
2:05 pm 107301 Cañares, RN, MAN

Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN Approved by: ANTONIA F. PASCUAL, RN, MN,MSN

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 Dean, PRC I.D. No. 0054229 Valid Until August 05, 2012

Date document is signed ____________________ Time _______________ Date document is signed____________________ Time _________________
Please specify Highest Nursing Degree Earned Master of Science in Nursing Specify Highest Nursing Degree Earned Master in
Nursing_______________ Master of Arts in Nursing_ _
Master of Science in Nursing______

(STRICTLY NO DESIGNATES)

UNIVERSITY OF SAN CARLOS ODC Form 2B


COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES O.R. SCRUB FORM
PHONE: 032 3433005; FAX 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph MINOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

SURGICAL SCRUB in Juan B. Dosado Memorial Hospital, Sugod, Cebu


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

Prepared by:

Printed Name with Signature of Student: JEZIEL JOY C. CORITICO


Patient’s INITIALS
Date Performed (only) SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
and (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

November 22,
J.M.V
2010 Episiorraphy Amalia C. Margallo, RN Khristle Ann C. Cañares, RN, MAN
02-45-92
8:20 AM

Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN Approved by: ANTONIA F. PASCUAL, RN, MN, MSN

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No 0190308 Valid Until June 22, 2011 Dean, PRC I.D. No. 0054229 Valid Until August 05,2012

Date document is signed ___________________ Time _________________ Date document is signed__________________ Time ______________

Please specify Highest Nursing Degree Earned Master of Science in Nursing Specify Highest Nursing Degree Earned Master in
Nursing___________ Master of Arts in Nursing____
Master of Science in Nursing__

(STRICTLY NO DESIGNATES)

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