D.R.

Form
ASSISTED DELIVERY
ATENEO DE ZAMBOANGA UNIVERSITY
FORM
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Reaccreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
ACTUAL DELIVERY in ZAMBOANGA CITY MEDICAL CENTER, ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: MENDOZA, EIREES JOY ATILANO
Date Performed
and
Time Started

Patients Initials

December 15, 2014

3:49 pm

S.G.
789698

Signature of Student__________________________

NATURE OF DELIVERY

Nurse On Duty
Name and Signature

SUPERVISED BY:
Clinical Instructor
Name and Signature

Normal Spontaneous Vaginal Delivery

Lloela D. Marian
RN

Angeline R. Cuizon
RM, RN, MN

Case Number

Noted by:
JOSEPHINE JUDITH PERANO-ALFORTE, RN, MN
Clinical Coordinator
PRC I.D. No. 0112157
Valid Until: 2016
PNA I.D. No. 2014-029901
Valid Until: 2014

Approved by:
MARIA LORNA BELLO-PABER, RN, MAN
Dean
PRC I.D. No. 0059150
Valid Until: 2016
PNA I.D. No. 6141
Valid Until: Lifetime Member
ADPCN No. 11-056

Valid Until: 2014

Date document is signed: _______________________ Time: ______________

Highest Degree Earned: MASTERS IN NURSING

Date document is signed: ________________________ Time: __________

Highest Degree Earned: MASTER OF ARTS IN NURSING

D.R. Form
ASSISTED DELIVERY
ATENEO DE ZAMBOANGA UNIVERSITY
FORM
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Reaccreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
ACTUAL DELIVERY in ZAMBOANGA CITY MEDICAL CENTER, ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: MENDOZA, EIREES JOY ATILANO
Date Performed
and
Time Started

Patients Initials

December 15, 2014

6:48 pm

R.A.
786895

Signature of Student__________________________

NATURE OF DELIVERY

Nurse On Duty
Name and Signature

SUPERVISED BY:
Clinical Instructor
Name and Signature

Normal Spontaneous Vaginal Delivery

Maria Victoria T. Reyes

RM, RN

Angeline R. Cuizon
RM, RN, MN

Case Number

Noted by:
JOSEPHINE JUDITH PERANO-ALFORTE, RN, MN
Clinical Coordinator
PRC I.D. No. 0112157
Valid Until: 2016
PNA I.D. No. 2014-029901
Valid Until: 2014

Approved by:
MARIA LORNA BELLO-PABER, RN, MAN
Dean
PRC I.D. No. 0059150
Valid Until: 2016
PNA I.D. No. 6141
Valid Until: Lifetime Member

ADPCN No. 11-056

Date document is signed: _______________________ Time: ______________
Highest Degree Earned: MASTERS IN NURSING

Valid Until: 2014

Date document is signed: ________________________ Time: __________

Highest Degree Earned: MASTER OF ARTS IN NURSING

D.R. Form
MANAGED DELIVERY
ATENEO DE ZAMBOANGA UNIVERSITY
FORM
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Reaccreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
ACTUAL DELIVERY in ZAMBOANGA CITY MEDICAL CENTER, ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: MENDOZA, EIREES JOY ATILANO
Date Performed
and
Time Started

Patients Initials

December 10, 2014

3:48 pm

L.M.
782556

Signature of Student__________________________

NATURE OF DELIVERY

Nurse On Duty
Name and Signature

SUPERVISED BY:
Clinical Instructor
Name and Signature

Normal Spontaneous Vaginal Delivery

Tetchie A. Castillo
RN

Angeline R. Cuizon
RM, RN, MN

Case Number

Noted by:
JOSEPHINE JUDITH PERANO-ALFORTE, RN, MN
Clinical Coordinator
PRC I.D. No. 0112157
Valid Until: 2016

Approved by:
MARIA LORNA BELLO-PABER, RN, MAN
Dean
PRC I.D. No. 0059150
Valid Until: 2016

PNA I.D. No. 2014-029901

Valid Until: 2014

Date document is signed: _______________________ Time: ______________

Highest Degree Earned: MASTERS IN NURSING

PNA I.D. No. 6141

Valid Until: Lifetime Member

ADPCN No. 11-056

Valid Until: 2014

Date document is signed: ________________________ Time: __________

Highest Degree Earned: MASTER OF ARTS IN NURSING

ICNB Form
IMMEDIATE CARE OF
ATENEO DE ZAMBOANGA UNIVERSITY
THE NEWBORN FORM
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Reaccreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
IMMEDIATE CORD CARE OF THE NEWBORN in ZAMBOANGA CITY MEDICAL CENTER, ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: MENDOZA, EIREES JOY ATILANO
Date Performed
and
Time Started

Patients Initials

December 10, 2014

pm

Baby Girl
788465

Noted by:

Case Number

Signature of Student__________________________

IMMEDIATE NEWBORN CORD

CARE PERFORMED

Nurse On Duty
Name and Signature

Cord Dressing
Delivery Room

Tetchie A. Castillo
RN

Approved by:

SUPERVISED BY:
Clinical Instructor
Name and Signature
Angeline R. Cuizon
RM, RN, MN

JOSEPHINE JUDITH PERANO-ALFORTE, RN, MN

Clinical Coordinator
PRC I.D. No. 0112157
Valid Until: 2016
PNA I.D. No. 2014-029901
Valid Until: 2014

MARIA LORNA BELLO-PABER, RN, MAN

Dean
PRC I.D. No. 0059150
Valid Until: 2016
PNA I.D. No. 6141
Valid Until: Lifetime Member
ADPCN No. 11-056

Date document is signed: _______________________ Time: ______________

Highest Degree Earned: MASTERS IN NURSING

Valid Until: 2014

Date document is signed: ________________________ Time: __________

Highest Degree Earned: MASTER OF ARTS IN NURSING