O.R.

Form 1B
O.R. CIRCULATING FORM
Minor

ATENEO DE ZAMBOANGA UNIVERSITY

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
Accreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 05, 2008-2013
SURGICAL SCRUB 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

B.B.

5:10 pm

Case Number

789148

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

Signature of Student__________________________

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty

Name and Signature

SUPERVISED BY:
Clinical Instructor
Name and Signature

Completion Curettage

Maria Victoria T. Reyes

RM, RN

Angeline R. Cuizon
RM, RN, MN

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: MASTER IN NURSING

Date document is signed: ________________________ Time: __________

Highest Degree Earned: MASTER OF ARTS IN NURSING