NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES

COTABATO CITY

CORD DRESS
Case Number:_______________________ Date Delivered:____________________ Time
Delivered:_________________
Name of Baby:_______________________________________________________Gender of
Baby:__________________
Name of
Mother:____________________________________________________________________________________
(First name)

(Middle name)

(Last name)

Weight:_______________________________
Length:________________________________________
Head Circumference:______________ Chest Circumference:______________ Abdominal
Circumference:_____________
Temperature:___________________________ Type of
Delivery:______________________________________________
Pediatrician on Duty:_________________________________ Obstetrician on
duty:______________________________
Nurse on Duty:______________________________________ Midwife on
duty:_________________________________
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________

_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________

Signature
OR Nurse
PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

CORD DRESS
Case Number:_______________________ Date Delivered:____________________ Time
Delivered:_________________
Name of Baby:_______________________________________________________Gender of
Baby:__________________
Name of
Mother:____________________________________________________________________________________
(First name)

(Middle name)

(Last name)

Weight:_______________________________
Length:________________________________________
Head Circumference:______________ Chest Circumference:______________ Abdominal
Circumference:_____________
Temperature:___________________________ Type of
Delivery:______________________________________________
Pediatrician on Duty:_________________________________ Obstetrician on
duty:______________________________
Nurse on Duty:______________________________________ Midwife on
duty:_________________________________
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________

___________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor

Signature
OR Nurse

PRC License No._____________

No._____________

NOTRE DAME UNIVERSITY

PRC License

COLLEGE OF HEALTH SCIENCES

COTABATO CITY

HANDLE

Case Number:________________________
Patients name:_______________________________________________________________________
Age:__________
(First name)

(Middle name)

Gravida:_________________
Living:_________________

Para:________________

Date of Delivery:___________________
Newborn:___________

Time

of

(Last name)

Abortion:____________________

Delivery:_______________________

Gender

of

Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Obstetrician
on
Duty:
by:_________________________________

_____________________________________

Nurse
on
duty:____________________________________________
duty:____________________________

Handled

Midwife

Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________

_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor

Signature
OR Nurse

PRC License No._____________

No._____________

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES

PRC License

on

COTABATO CITY

HANDLE

Case Number:________________________
Patients
Age:__________

name:_______________________________________________________________________
(First name)

(Middle name)

Gravida:_________________
Living:_________________

Para:__________________

Date of Delivery:___________________
Newborn:_____________

Time

of

(Last name)

Abortion:_________________

Delivery:__________________

Gender

of

Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Obstetrician
on
Duty:
by:______________________________

____________________________________

Nurse
on
duty:_______________________________________
duty:____________________________

Handled

Midwife

on

Handled
(student):________________________________________________________________________________

by

Assisted
(student):________________________________________________________________________________

by

Cord
Dressed
(student):____________________________________________________________________________

by

Name
Institution:_________________________________________________________________________________

of

___________________________________
_________________________________
Signature over Printed Name
over Printed Name

Signature

Clinical Instructor

OR Nurse

PRC License No._____________

No._____________

PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

ASSIST

Case Number:________________________
Patients name:_______________________________________________________________________
Age:__________
(First name)

(Middle name)

Gravida:_________________
Living:____________________

Para:________________

Date of Delivery:___________________
Newborn:_____________

Time

of

(Last name)

Abortion:_________________

Delivery:__________________

Gender

of

Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Obstetrician
on
Duty:
by:________________________________

__________________________________

Nurse
on
duty:_______________________________________
duty:____________________________

Handled

Midwife

Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________

_________________________________
_________________________________
Signature over Printed Name
over Printed Name

Signature

Clinical Instructor

OR Nurse

PRC License No._____________

No._____________

PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

on

ASSIST

Case Number:________________________
Patients
Age:__________

name:_______________________________________________________________________
(First name)

Gravida:_________________
Living:_________________

(Middle name)

Para:________________

Date of Delivery:___________________
Newborn:_____________

Time

of

(Last name)

Abortion:___________________

Delivery:__________________

Gender

of

Type of Delivery:_______________________________________________________________________________
Final diagnosis:_________________________________________________________________________________
__________________________________________________________________________________________________
_______________________________________________________________________________________________
Obstetrician
on
Duty:
by:________________________________

__________________________________

Nurse
on
duty:_______________________________________
duty:____________________________

Handled

Midwife

on

Handled
(student):________________________________________________________________________________

by

Assisted
(student):________________________________________________________________________________

by

Cord
Dressed
(student):____________________________________________________________________________

by

Name
Institution:_________________________________________________________________________________

of

____________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________

Signature
OR Nurse
PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

MINOR

Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________

Operation

Patients name:__________________________________________________________________Sex:______
Age:______
(First name)

(Middle name)

(Last name)

Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_

Surgeon: ______________________________________ _ Assistant Surgeon:

___________________________________
Anesthesiologist:_________________________________ Type of
Anesthesia:___________________________________
OR Scrub
Nurse:_____________________________________________________________________________________
Student Scrub
Nurse:_________________________________________________________________________________
Student Circulating
Nurse:_____________________________________________________________________________
Name of
Institution:__________________________________________________________________________________

_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________

Signature
OR Nurse
PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

MINOR

Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________

Operation

Patients name:__________________________________________________________________Sex:______
Age:______
(First name)

(Middle name)

(Last name)

Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_

Surgeon: ______________________________________ _ Assistant Surgeon:

___________________________________
Anesthesiologist:_________________________________ Type of
Anesthesia:___________________________________
OR Scrub
Nurse:_____________________________________________________________________________________
Student Scrub
Nurse:_________________________________________________________________________________
Student Circulating
Nurse:_____________________________________________________________________________
Name of
Institution:__________________________________________________________________________________

________________________________
______________________________

__

Signature over Printed Name

over Printed Name

Signature

Clinical Instructor

OR Nurse

PRC License No._____________

No._____________

PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

MAJOR

Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________

Operation

Patients name:__________________________________________________________________Sex:______
Age:______
(First name)

(Middle name)

(Last name)

Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_

Surgeon: ______________________________________ _ Assistant Surgeon:

___________________________________
Anesthesiologist:_________________________________ Type of
Anesthesia:___________________________________
OR Scrub
Nurse:_____________________________________________________________________________________
Student Scrub
Nurse:_________________________________________________________________________________
Student Circulating
Nurse:_____________________________________________________________________________
Name of
Institution:__________________________________________________________________________________

_________________________________
_________________________________
Signature over Printed Name
over Printed Name

Signature

Clinical Instructor

OR Nurse

PRC License No._____________

No._____________

PRC License

NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

MAJOR

Case Number:________________________
Date:_________________________________
Operation Started:____________________
Ended:_______________________

Operation

Patients name:__________________________________________________________________Sex:______
Age:______
(First name)

(Middle name)

(Last name)

Address:_________________________________________________________________________________________
__
Operation
Done:____________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
_______________________________________________________________________________________________________________________
_

Surgeon: ______________________________________ _ Assistant Surgeon:

___________________________________
Anesthesiologist:_________________________________ Type of
Anesthesia:___________________________________
OR Scrub
Nurse:_____________________________________________________________________________________
Student Scrub
Nurse:_________________________________________________________________________________
Student Circulating
Nurse:_____________________________________________________________________________

Name of
Institution:__________________________________________________________________________________

________________________________
______________________________

__

Signature over Printed Name

over Printed Name

Signature

Clinical Instructor
PRC License No._____________
No._____________

OR Nurse
PRC License