Capitol University

College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City (CHED 070: PACUCOA Level 2, June 14, 1982 Manila)

ODC Form 2A
O.R. SCRUB FORM Major

SURGICAL SCRUB in Northern Mindanao Medical Center Hospital, Municipality/City/Province Prepared by: Maria Sol Fontillas Aguirre
____________________________ Year of Admission in the BSN Program: Year Graduated in BSN Program: June 2007 October 2011

Printed Name and Signature of Student:

No.
1 2 3 4 5

Date Performed

Time Started

Case No.

Patients Name

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name & Signature)

Supervised by Name and Signature of C.I.

Noted by: ________ Mrs. Jenny R. Balo, R.N., M.A.N._____________ (Print Name & Signature) Clinical Coordinator, PRC I.D. No.: _0257481__ Valid Until: June 20, 2012_ Date Document is signed: __________________ Time: _________________ Highest Nursing Degree Earned: ___R.N., M.A.N.____

Approved by: ______ Mrs. Fidela B. Ansale, R.N., M.A.N._______ (Print Name & Signature) Dean, PRC I.D. No.: ____0085045____ Valid Until: February 7, 2010_

Date Document is signed: ____________ Time: ____________________ Highest Nursing Degree Earned: ___B.S.N., M.A.N.____

Capitol University
College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City (CHED 070: PACUCOA Level 2, June 14, 1982 Manila)

ODC Form 2C
O.R. SCRUB FORM Minor

SURGICAL SCRUB in Northern Mindanao Medical Center/ Cagayan de Oro Medical Center/ Capitol University Medical City Hospital, Municipality/City/Province Prepared by: Maria Sol Fontillas Aguirre
____________________________ Year of Admission in the BSN Program: Year Graduated in BSN Program: June 2007 October 2011

Printed Name and Signature of Student:

No.

Date Performed
February 19, 2011

Time Started
4:30pm

Case No.
2664

Patients Name
Marlene Oca

SURGICAL PROCEDURE PERFORMED

Creation of Anteriovenous Fistula Left Arm and Forearm Lumpectomy Right Breast

O.R. Nurse On Duty (Name & Signature)

Cyrille Mae Cahoy, RN

Supervised by Name and Signature of C.I.

Caesar Puerto, RN

2 3 4 5

April 25, 2011

8:50am

016207

Joy Monteza

Airen Salbadana, RN

Jessele B. Janioso, RN, MN Marithel R. Moreno, RN, MN Bergris M. Puerto, RN, MN Marithel R. Moreno, RN, MN

April 29, 2011 August 13, 2011

2:08pm 5:00pm

497886 00739

Yllor Dan Mari Jayo Roger L. Sale

Circumcision Debridement of Wound

Giovanni Capistrano, RN Niel Frank Deidora, RN

August 19, 2011

3:15pm

552103

Danica Paulino

Excision

Giovanni Capistrano, RN

Noted by: _________ Mrs. Jenny R. Balo, R.N., M.A.N.____________ (Print Name & Signature) Clinical Coordinator, PRC I.D. No.: _0257481__ Valid Until: June 20, 2012_ Date Document is signed: __________________ Time: _________________ Highest Nursing Degree Earned: ___R.N., M.A.N.____

Approved by: ______ Mrs. Fidela B. Ansale, R.N., M.A.N._______ (Print Name & Signature) Dean, PRC I.D. No.: ____0085045____ Valid Until: February 7, 2010_

Date Document is signed: ____________ Time: ____________________ Highest Nursing Degree Earned: ___B.S.N., M.A.N.____

Capitol University
College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City (CHED 070: PACUCOA Level 2, June 14, 1982 Manila)

ODC Form 2B
O.R. CIRCULATING FORM

SURGICAL SCRUB in Northern Mindanao Medical Center/ Capitol University Medical City Hospital, Municipality/City/Province

Prepared by:

Maria Sol Fontillas Aguirre

____________________________ SURGICAL PROCEDURE PERFORMED

Year of Admission in the BSN Program: Year Graduated in BSN Program: O.R. Nurse On Duty (Name & Signature)

June 2006 October 2009

Printed Name and Signature of Student: Date Performed Time Started

No.
1 2 3 4 5

Case No.

Patients Name

Supervised by Name and Signature of C.I.

Noted by: _________ Mrs. Jenny R. Balo, R.N., M.A.N.____________ (Print Name & Signature) Clinical Coordinator, PRC I.D. No.: _0257481__ Valid Until: June 20, 2012_ Date Document is signed: __________________ Time: _________________ Highest Nursing Degree Earned: ___R.N., M.A.N.____

Approved by: ______ Mrs. Fidela B. Ansale, R.N., M.A.N._______ (Print Name & Signature) Dean, PRC I.D. No.: ____0085045____ Valid Until: February 7, 2010_

Date Document is signed: ____________ Time: ____________________ Highest Nursing Degree Earned: ___B.S.N., M.A.N.____