As adopted by Far Eastern University- Dr.

Nicanor Reyes Medical Foundation School of Nursing

ODC Form 2A
O.R. SCRUB
FORM
Far Eastern University- Dr. Nicanor Reyes Medical Foundation MAJOR
Regalado Avenue, near Dahlia Street, West Fairview, Quezon City, Philippines 1118
Tel. 427- 0213 Loc. 1147/ Website: www.feu-nrmf.edu.ph
with Government Recognition No. 046 Series OF 2007, CHED (Per CEB Resolution Number 229- 2007)
SURGICAL SCRUB in Far Eastern University – Dr. Nicanor Reyes Medical Foundation/ Regalado Avenue, West Fairview, Quezon City

Prepared by: _____DARYL HERMINIGILDO RAMOS Student Number: ___2007AN218___

(Printed Name and Signature of Student)

Patient’s Initial
Date Performed Only SURGICAL PROCEDURE O.R. Nurse On Duty Signature Supervised by Signature
and PERFORMED (Clinical Instructor)
Time Started Case Number

July 08, 2009 L.H.C. Extra-fascial Hysterectomy OMAR K. LUIS, R.N. DOREEN M. CERVANTES,
07:00AM 24646 Bilateral Salphingo- R.N., M.A.N.
Oophorectomy
January 11, 2010 R.D.S. Excess Biopsy with Frozen DOREEN MANARPIIS, R.N. DOREEN M. CERVANTES,
07:00AM 32178 Section Modified Radical R.N., M.A.N.
Mastectomy
June 23, 2010 A.F.M. Reversal of Hartmann’s FELLE ADELITZ GERARDINE D. JOSAN M. REYES, R.N.,
08:20AM 34255 Procedure SAMALA, R.N. M.A.N.
June 29, 2010 L.J.B. Total Thyroidectomy AARON ADRIANO, R.N. JOSAN M. REYES, R.N.,
09:05AM 34406 M.A.N.
June 29, 2010 L.M.C. Phacoemulsification with FELLE ADELITZ GERARDINE D. JOSAN M. REYES, R.N.,
01:15PM 062110 Posterior Chamber SAMALA, R.N. M.A.N.
Intraocular Lens, Right Eye

Noted by: Approved by:

TRINA C. TAN, RN, MAN TITA YAP- CRUZ, RN, MAN, Ed. D.
Clinical Coordinator Dean, School of Nursing
PRC ID. No. ___________ Valid Until _______________________ PRC ID. No. _____38788_____ Valid Until _September 29,
2011__
Date Documented is signed: ____________________________ Date Documented is signed: _____________________________
 Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN,
Ed.D.

As adopted by Far Eastern University- Dr. Nicanor Reyes Medical Foundation School of Nursing
ODC Form 2B
O.R. MINOR
FORM
Far Eastern University- Dr. Nicanor Reyes Medical Foundation
Regalado Avenue, near Dahlia Street, West Fairview, Quezon City, Philippines 1118
Tel. 427- 0213 Loc. 1147/ Website: www.feu-nrmf.edu.ph
with Government Recognition No. 046 Series OF 2007, CHED (Per CEB Resolution Number 229- 2007)
SURGICAL SCRUB in Far Eastern University – Dr. Nicanor Reyes Medical Foundation/ Regalado Avenue, West Fairview, Quezon City

Prepared by: _____DARYL HERMINIGILDO RAMOS_____ Student Number: ___2007AN218___

(Printed Name and Signature of Student)

Patient’s Initial
Date Performed Only SURGICAL PROCEDURE O.R. Nurse On Duty Signature Supervised by Signature
and PERFORMED (Clinical Instructor)
Time Started Case Number

January 13, 2010 J.P.R.D. Removal of Internal Fixation CHARISSE CANDELARIA, R.N. DOREEN M. CERVANTES,
10:20 AM 32274 (Titanium Plates and R.N., M.A.N.
Screws)
March 08, 2010 A.F.D. Chalazion, Right Upper Lid EVELYN ALBANIA, R.N. MELANIE GRACE S.
11:30 AM 10-00194 Status Post Incision and FRANCISCO, R.N., M.A.N.
Curettage, Right Upper Lid
March 10, 2010 M.J.A. Multiple Acrocordon both EVELYN ALBANIA, R.N. MELANIE GRACE S.
09:00 AM 10-00206 Preauricular Area, Excision FRANCISCO, R.N., M.A.N.
Biopsy
March 17, 2010 L.A.C. Jr. Release of Trigger Finger EVELYN ALBANIA, R.N. MELANIE GRACE S.
01:30 PM 10-00223 FRANCISCO, R.N., M.A.N.
June 22, 2010 I.N.T. Open Rhinoplasty with Tip CHARISSE CANDELARIA, R.N JOSAN M. REYES, R.N.,
08:35AM 34236 Plasty, Excision of M.A.N.
Siliconoma with Biopsy

Noted by: Approved by:

TRINA C. TAN, RN, MAN TITA YAP- CRUZ, RN, MAN, Ed. D.
 Clinical Coordinator
PRC ID. No. ___________ Valid Until _______________________
2011__
Date Documented is signed: ____________________________
Please specify Highest Nursing Degree Earned: MAN
Ed. D
Dean, School of Nursing
PRC ID. No. _____38788_____ Valid Until _September 29,
Date Documented is signed: _____________________________
Please specify Highest Nursing Degree Earned: MAN,