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ODC Form 2A

O.R. SCRUB FORM


MAJOR
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student: ENRIQUEZ, HENDRIX ANTONNI AMANTE

Date Performed Patient’s INITIALS (only) SUPERVISED BY:


SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
ODC Form 2B
O.R. FORM
MINOR
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
SURGICAL SCRUB in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed Patient’s INITIALS (only) SUPERVISED BY:


SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
ODC Form 1A
ACTUAL DELIVERY
FORM
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
ACTUAL DELIVERY in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Patient’s INITIALS (only) D.R. Nurse On Duty


Date Performed SUPERVISED BY:
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Case Number
(If Midwife on Duty,
Time Started (not applicable for Birthing /Lying –In Clinics /
Signature is not Required)
Name and Signature
Homes)

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
ODC Form 1B
ASSISTED DELIVERY
FORM
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
ASSISTED DELIVERY in
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Patient’s INITIALS (only) D.R. Nurse On Duty


Date Performed SUPERVISED BY:
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Case Number
(If Midwife on Duty,
Time Started (not applicable for Birthing /Lying –In Clinics /
Signature is not Required)
Name and Signature
Homes)

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
ODC Form 1C
CORD CARE FORM

WESTERN MINDANAO STATE UNIVERSITY


Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level II Re-accredited / February 2009
IMMEDIATE NEWBORN CORD CARE in Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student: ENRIQUEZ, HENDRIX ANTONNI AMANTE

Patient’s INITIALS (only) Immediate Newborn Cord Care D.R. Nurse On Duty
Date Performed SUPERVISED BY:
and Case Number PERFORMED (Name and Signature) Clinical Instructor
Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty,
Time Started (not applicable for Birthing /Lying –In
Signature is not Required)
Name and Signature
Clinics / Homes) NICU, or Home

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing

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