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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
Prepared by:
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_________
(STRICTLY NO DESIGNATES)
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
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)
IMMEDIATE NEWBORN CORD CARE in Juan B. Dosado Memorial Hospital, Sugod, Cebu
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
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)
Prepared by:
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)
Noted by: LAARNE E. PONTILLAS, RN, MSN, MAN Approved by: ANTONIA F. PASCUAL, RN, MN,MSN
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)
Prepared by:
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
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)