Saint Marys University

SCHOOL OF HEALTH SCIENCES

ODC Form 1A

Bayombong, Nueva Vizcaya

ACTUAL DELIVERY FORM

e-mail:smunet@smu.edu.ph
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126* (078) 321-2217

ACTUAL DELIVERY in Gov. Faustino Dy. Sr. Memorial Hospital/

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.

Date Performed
And
Time Started

Patients INITIALS Only

Case Number
(not applicable for Birthing/
Lying-In Clinics/Homes)

D.R. Nurse On Duty

(Name and Signature),
(If Midwife on Duty,
Signature Not Required)

PROCEDURE
PERFORMED

Noted by: ______________________________________________________________________

Printed Name and Signature
Clinical Coordinator,PRC I.D. No. _______________________ Valid Until _________________
Date document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ____________________________________________________________________

Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________

(STRICTLY NO DESIGNATES)

Saint Marys University

SCHOOL OF HEALTH SCIENCES

ODC Form 2A

Bayombong, Nueva Vizcaya

e-mail:smunet@smu.edu.ph
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217

O.R SCRUB FORM

Major

O.R Srub in Gov. Faustino Dy. Sr. Memorial Hospital

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.

Date Performed
And
Time Started

Patients INITIAL Only

Case Number

SURGICAL PROCEDURE
PERFORMED

Noted by: ______________________________________________________________________

Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Dated document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________

O.R. Nurse On Duty

(Name and Signature),

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ____________________________________________________________________

Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________

(STRICTLY NO DESIGNATES)

Saint Marys University

SCHOOL OF HEALTH SCIENCES

ODC Form 1B

Bayombong, Nueva Vizcaya

ASSISTED DELIVERY FORM

e-mail:smunet@smu.edu.ph
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217

ACTUAL DELIVERY in Gov. Faustino Dy. Sr. Memorial Hospital

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.

Date Performed
And
Time Started

Patients INITIAL Only

Case Number
(not applicable for Birthing/
Lying-In Clinics/Homes)

PROCEDURE
PERFORMED
ASSISTED DELIVERY

Noted by: ______________________________________________________________________

Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Date document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________

D.R. Nurse On Duty

(Name and Signature),
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ____________________________________________________________________

Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________

(STRICTLY NO DESIGNATES)

Saint Marys University

SCHOOL OF HEALTH SCIENCES

ODC Form 2B

Bayombong, Nueva Vizcaya

O.R CIRCULATING FORM

e-mail:smunet@smu.edu.ph
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217

O.R CIRCULATING in Gov. Faustino Dy. Sr. Memorial Hospital

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.____

Date Performed
And
Time Started

Patients INITIAL Only

Case Number

SURGICAL PROCEDURE
PERFORMED

Noted by: ______________________________________________________________________

Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Dated document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________

O.R. Nurse On Duty

(Name and Signature),

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ____________________________________________________________________

Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________

(STRICTLY NO DESIGNATES)

Saint Marys University

SCHOOL OF HEALTH SCIENCES

ODC Form 1C

Bayombong, Nueva Vizcaya

CORD CARE FORM

e-mail:smunet@smu.edu.ph
website: www.smu.edu.ph
Tel No.: (078) 321-2221, 321-4436 Loc. 126 * (078) 321-2217

ACTUAL DELIVERY in Veterans Regional Hospital

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: _____ MEDINA, MARK JAYSON C.

Date Performed
And
Time Started

Patients INITIALS Only

Immediate Newborn Cord Care

PERFORMED

Case Number
(not applicable for Birthing/
Lying-In Clinics/Homes)

Indicate where performed e.g. D.R., Nursery

NICU, or Home

Noted by: ______________________________________________________________________

Printed Name and Signature
Clinical Coordinator, PRC I.D. No. _______________________ Valid Until _________________
Date document is signed: _______________________________ Time_____________________
Please specify Highest Nursing Degree Earned: _________________________________________

D.R. Nurse On Duty

(Name and Signature),
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ____________________________________________________________________

Printed Name and Signature
Dean, PRC I.D. No. ___________________________________ Valid Until ___________________
Date document is signed: _______________________________ Time_______________________
Please specify Highest Nursing Degree Earned: __________________________________________

(STRICTLY NO DESIGNATES)