Cases

ODC Form 1 O.R.
SCRUB FORM
UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

Brgy. San Gabriel, General Mariano Alvarez, Cavite
PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: uphsgma_nursing@yahoo.com, Website: uphsl.edu.ph
SURGICAL SCRUB in New Sinai MDI Hospital, Sta Rosa, Laguna (Major) Hospital, Municipal/City/Province Prepared by: Name of Student _Jane O. Pareja_____________________________ ____________________________________ Signature of Student
Date Performed and Time Started 8-24-2010 9:00 a.m.
Patients Name
PROCEDURE PERFORMED
Case Number Carmelita Cruz 10-2799 Total Abdominal Hysterectomy
O.R. Nurse On Duty (Name only) Regine Ong-iko,RN
SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva,RN,MAN
Manuel G. Almelor,MD,RN,MAN
Noted by: Chief Nurse
PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by:
Concurred by:
JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator
__
PRC I.D No. 0295145 Valid Until August 05, 2011 . PNA No. Valid Until . Date document is signed: Time__ _____________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
ZENY C. MINA, R.N., MAN Dean Valid Until November 2010 PNA No. 10134 PRC I.D No. 114856 ADPCN No. 0396 Valid Until April 2011 Date document is signed: Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
Valid until Lifetime . Time____________________ .
ODC Form 1 O.R. SCRUB FORM

SURGICAL SCRUB in New Sinai, MDI Hospital, Sta. Rosa, Laguna (Major) Hospital, Municipal/City/Province Signature of Student
Prepared by: Name of Student __Jane O. Pareja____________________________ ____________________________________
Patients Name
PROCEDURE PERFORMED
Case Number Sheryll Maturan 2615 Repeat Low Transveres Cesarian section with Bilateral tubal ligation
O.R. Nurse On Duty (Name only)
SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva,RN, MAN
Manuel Almelor,MD,RN,MAN
Concurred by:
__
ZENY C. MINA, R.N., MAN Dean PRC I.D No. 114856 Valid Until November 2010 PNA No. 10134 Valid Until April 2011 Date document is signed: ADPCN No. 0396 Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

SURGICAL SCRUB in UPHS-Dr. Tamayo Medical Center,Binan, Laguna (Major) Hospital, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ______________________________ ____________________________________ Signature of Student
Patients Name
PROCEDURE PERFORMED
Case Number Rouel Bangao 64378 Craniotomy
O.R. Nurse On Duty (Name only) Raymond ChrisTa-A RN,RM
SUPERVISED BY Clinical Instructor Name and Signature Jennifer T. Navarro,RN,MAN
11-13-2010 9:44 a.m.
Charles Jayson Carino 66985
Cholecystectomy
Aisa Memillo,RN
Glen Daquiz,RN,MAN

Concurred by:
__

SURGICAL SCRUB in Concepcion District Hospital,Concepcion, Tarlac (Major) Hospital, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ______________________________ ____________________________________ Signature of Student
Date Performed and Time Started 05-04-2010 3:25 p.m.
Patients Name
PROCEDURE PERFORMED
Case Number Agnes Bucasas 10-05-252 Low Transveres Cesarian section II
O.R. Nurse On Duty (Name only) Perpetua Liwanag,RN
SUPERVISED BY Clinical Instructor Name and Signature Aldalyn Datul,PTRP,RN,MAN

PRC I.D. No. PNA No. Date document is signed: Valid Until Valid Until Time
Concurred by:
PRC I.D No. 0295145 PNA No. Date document is signed:

Valid Until Valid Until August 05, 2011
__
. . Time__ _____________
Please specify Highest Nursing Degree Earned: Approved by:
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing ZENY C. MINA, R.N., MAN De PRC I.D No. 114856 Valid Until November 2010 PNA No. 1

SURGICAL SCRUB (Major) Jane O. Pareja
in
Concepcion District Hospital, Concepcion , Tarlac Hospital, Municipal/City/Province Signature of Student
Prepared by: Name of Student ______________________________ ____________________________________
Patients Name
PROCEDURE PERFORMED
Case Number Agnes Bucasas 10-05-252 Low Transveres cesarian section II
O.R. Nurse On Duty (Name only) Perpetua Liwanag,RN
SUPERVISED BY Clinical Instructor Name and Signature Aldalyn Datul,PTRP,RN,MAN
Celia Laberinto, RN,MAN

PRC I.D. No. 53774 Valid Until PNA No. 5351 Valid Until Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by: May 2011 Lifetime
Concurred by:
__
. .
PRC I.D No. 0295145 Valid Until August 05, 2011 PNA No. Valid Until Date document is signed: Time__ _____________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
ZENY C. MINA, R.N., MAN Dean
PRC I.D No. 114856 Valid Until November 2010 PNA No. 10134 Valid Until April 2011 Date document is signed: ADPCN No. 0396 Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

SURGICAL SCRUB in (Major)
Hospital, Municipal/City/Province Signature of Student
Date Performed and Time Started
Patients Name
PROCEDURE PERFORMED
Case Number
SUPERVISED BY Clinical Instructor Name and Signature

Valid Until PRC I.D. No. PNA No. Valid Until Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by: PRC I.D No. 114856 Valid Until
Concurred by:
__
PRC I.D No. 0295145 Valid Until August 05, 2011 . PNA No. Valid Until . Date document is signed: Time__ _____________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing ZENY C. MINA, R.N., MAN Dean November 2010 PNA No. 10134
Valid until
Lifetime
ADPCN No. 0396 Valid Until April 2011 Date document is signed: Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
Time____________________ .

SURGICAL SCRUB in New Sinai MDI Hospital, Sta. Rosa, laguna (Minor) Hospital, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ______________________________ ____________________________________ Signature of Student
Date Performed and Time Started 08-16-2010 2:05p.m.
Patients Name
PROCEDURE PERFORMED
Case Number Minerva Ramos 10-2775 Alar trimming with nasal bunching
O.R. Nurse On Duty (Name only) Rose Ann Yambao,RN
SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva, RN,MAN
08-16-2010 5:37 p.m.
Jayson Rasqueta 10-2776
Wound debridement
Mark Maniago,RN
Melissa Caliva,RN,MAN
Noted by:
Manuel Almelor ,MD, RN,MAN Chief Nurse
Concurred by:
PRC I.D. No. Valid Until PNA No. Valid Until Time Date document is signed: Please specify Highest Nursing Degree Earned: Approved by:
ZENY C. MINA, R.N., MAN Dean PRC I.D No. 114856 Valid Until November 2010 PNA No. 10134 ADPCN No. 0396 Valid Until April 2011 Date document is signed: Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

SURGICAL SCRUB in New Sinai MDI Hospital,Sta Rosa ,Laguna (MINOR) Hospital, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ______________________________ ____________________________________ Signature of Student
Patients Name
PROCEDURE PERFORMED
Case Number Albina Celada 2599 Extra Capsular Cataract Extraction with intra ocular lense (OD)
SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva,RN,MAN
08-16-2010 7:30p.m.
Paul Baron 10-2777
Suprapubic tube cystectomy
Regine Ang-iko
Melissa Caliva,RN,MAN
Noted by: YANEZA, R.N., MAN
Manuel Almelor,MD,RN,MAN __ Chief Nurse
Concurred by: Clinical Coordinator
JONATHAN R.
PRC I.D. No. Valid Until Valid Until PNA No. Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by:
NIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

(Minor)
SURGICAL SCRUB in FORT BONIFACIO HOSPITAL,Taguig, Manila Hospital, Municipal/City/Province Signature of Student
Prepared by: Jane O. Pareja Name of Student ______________________________ ____________________________________
Patients Name
PROCEDURE PERFORMED
Case Number Gerardo Navarro 4779 Multiple Warts electrocautery
O.R. Nurse On Duty (Name only) Ma. Lourdes B. Rosero,RN
SUPERVISED BY Clinical Instructor Name and Signature Rizalina B. Ragudo,RN,MAN
Noted by:
00071483
Col Fe C. Mahor (GSC) Chief Nurse
Concurred by:
PRC I.D. No. Valid Until 11-10-11 PNA No. 8295 Valid Until lifemember Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by: PRC I.D No. ADPCN No. 114856 0396 Valid Until Valid Until
ZENY C. MINA, R.N., MAN Dean November 2010 PNA No. 10134 April 2011 Date document is signed:
Valid until Lifetime . Time____________________
Please specify Highest Nursing Degree Earned:
Master of Arts in Nursing
ODC Form 2 ACTUAL DELIVERY

ACTUAL DELIVERY in Rural Health Unit, General Mariano Alvarez, Cavite Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student __________________ ____________________________________ Signature of Student
Patients Name Case Number

(Not applicable for Birthing/LyingIn Clinics/Homes)
PROCEDURE PERFORMED
Normal Spontaneous Vaginal Delivery
O.R. Nurse / Midwife On Duty (Name only) Anabeth Panis,RHM
SUPERVISED BY Clinical Instructor Name and Signature Rodeth A. Lopera,RN,MAN
Leoniza F. Taginad

Concurred by:
__


PROCEDURE PERFORMED
O.R. Nurse / Midwife On Duty (Name only) Thelma C. Ocampo,RN
SUPERVISED BY Clinical Instructor Name and Signature Araceili R. Amurao,RM,RN,MAN
Regina S. Maravillo
07-27-2009
Josephine Cedollo
Normal Spontaneous delivery
Thelma C. Ocampo,RN
Araceili R. AmuraoRM,RN,MAN

Concurred by:
__

07-28-2009Brgy. San Gabriel, General Mariano Alvarez, Cavite

(Not applicable for Birthing/Lying-In Clinics/Homes)
PROCEDURE PERFORMED
O.R. Nurse / Midwife On Duty (Name only)
SUPERVISED BY Clinical Instructor Name and Signature Araceili R. Amurao,RM,RN,M AN
07-29-2009
Mary Rose A. Canete
Thelma C. Ocampo,RN
Araceili R. Amurao,RM,RN,M AN
07-28-2009
Celybeth M. Diago
Normal spontaneous delivery
Thelma C. Ocampo,RN
IVERSITY OF PERPETUA L HELP SYSTEMGMA CAMPUS

PHONE #: (02)4907748, Fax #: (046)890-1393, Email Add: uphsgma_nursing @yahoo.com, Website: uphsl.edu.ph
ACTUAL DELIVERY in Rural Health Unit, General Mariano Alvarez, Cavite Hospital/Home/L ying-In-Clinic, Municipal/City/Pr ovince Prepared by: Name of Student _______________ ___

(Not applicable for Birthing/Lying-In Clinics/Homes)
PROCEDURE PERFORMED
Leoniza F. Taginad
Noted by: Concurred by: JONATHAN R. YANEZA, R.N., MAN __ Chief Nurse Clinical Coordinator
PRC I.D. No. Valid Until PRC I.D No. 0295145 Valid Until August 05, 2011 . PNA No. Valid Until PNA No. Valid Until . Date document is signed: Time Date document is signed: Time__ _____________ Please specify Highest Nursing Degree Earned: Please specify
Highest Nursing Degree Earned: Master of Arts in Nursing
Approved by: ZENY C. MINA, R.N., MAN
Dean PRC I.D No. 114856 Valid Until November 2010 PNA No. 10134 Valid until Lifetime . ADPCN No. 0396 Valid Until April 2011 Date document is signed: Time____________ ________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing .

PRC I.D. No. PNA No. Date document is signed: Valid Until Valid Until Time
Concurred by:
PRC I.D No. 0295145 PNA No. Date document is signed:

__
. . Time__ _____________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
ODC Form 3 D.R. ASSIST FORM

ASSISTED DELIVERY in Rural Health Center, General Mariano Alvarez, Cavite Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ______________ ____________________________________ Signature of Student
Date Performed and Time Started 06-07-2009

PROCEDURE PERFORMED
Normal Spontaneous Delivery
D.R. Nurse / Midwife On Duty (Name only) Thelma C.Ocampo
Joan A. Rotario
06-16-2009
Rolena A. Rarugol
Normal Spontaneous Delivery
Thelma C, Ocampo
Araceili R. Amurao,RM,RN,MAN

PRC I.D. No. Valid Until Valid Until PNA No. Date document is signed: Time Please specify Highest Nursing Degree Earned:
Concurred by:
__
Approved by:

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN
ASSISTED DELIVERY in Rural Health in General Mariano Alvarez,Cavite Hospital/Home/Lying-In-Clinic, Municipal/City/Province Jane O. Pareja Prepared by: Name of Student ______________ ____________________________________ Signature of Student

PROCEDURE PERFORMED
D.R. Nurse / Midwife On Duty (Name only) Thelma C. Ocampo
Maricho C. Sagaray

PRC I.D. No. Valid Until Valid Until PNA No. Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by: PRC I.D No. 114856 Valid Until
Concurred by:
__
Valid until
Lifetime
Time____________________ .


PROCEDURE PERFORMED
Erlinda E. Roque
06-28-2009
Maribel Pebreo Gabo
Thelma C. Ocampo

Valid Until PRC I.D. No. PNA No. Valid Until Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by: PRC I.D No. ADPCN No. 114856 0396 Valid Until Valid Until
Concurred by:
__
PRC I.D No. 0295145 Valid Until August 05, 2011 . PNA No. Valid Until . Date document is signed: Time__ _____________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing ZENY C. MINA, R.N., MAN Dean November 2010 PNA No. 10134 April 2011 Date document is signed:
Valid until Lifetime . Time____________________
Please specify Highest Nursing Degree Earned:
Master of Arts in Nursing


PROCEDURE PERFORMED
Maricho C. Sagaray

Valid Until PRC I.D. No. PNA No. Valid Until Time Date document is signed: Please specify Highest Nursing Degree Earned: Approved by:
Concurred by:
__

(Major)
SURGICAL SCRUB in Hospital, Municipal/City/Province Signature of Student
Patients Name
PROCEDURE PERFORMED
Case Number

Concurred by:
__

PHONE #:(02)490-7748, Fax #: (046)890-1393, Email Add: uphsgma_nursing@yahoo.com, Website: uphsl.edu.ph
ODC Form 4 D.R. IMMEDIATE NEWBORN
IMMEDIATE NEWBORN CORD CARE in Concepcion Lying In Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ____________________________________ Signature of Student

Immediate Newborn Cord Care Performed

Indicate where performed e.g. D.R., Nursery, NICU, or Home Delivery room
D.R. Nurse / Midwife On Duty (Name only) Eliza C. Concepcion,RM
SUPERVISED BY Clinical Instructor Name and Signature Glenn A. Daquiz,RN,MAN
Baby Girl Manalong
09-20-2010 3:30 p.m. Noted by:
Baby boy Morales
Delivery room
Eliza C. Concepcion,RM
Glenn A. Daquiz,RN,MAN
Concurred by: Chief Nurse
__
PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Please specify Highest Nursing Degree Earned: Approved by: PRC I.D No. 114856 Valid Until
Valid until
Lifetime
Time____________________ .

IMMEDIATE NEWBORN CORD CARE in Rural Health Center,General Mariano Alvarez, Cavite Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student Jane O. Pareja ____________________________________ Signature of Student


D.R. Nurse / Midwife On Duty (Name only) Thelma C. Ocampo,RN
Baby boy Requina

Concurred by:
__
PRC I.D No. 0295145 Valid Until August 05, 2011 . PNA No. Valid Until . Date document is signed: Time__ _____________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing ZENY C. MINA, R.N., MAN
Dean PRC I.D No. 114856 Valid Until November 2010 PNA No. 10134 ADPCN No. 0396 Valid Until April 2011 Date document is signed: Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

IMMEDIATE NEWBORN CORD CARE in Rural Health Center, General Mariano Alvarez,Cavite Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Jane O. Pareja Name of Student ____________________________________ Signature of Student


Baby girl Enuerzo
07-01-2009 5:49p.m. Noted by:
Baby girl Aguirre
Delivery room
Thelma C. Ocampo
Concurred by: Chief Nurse

Valid Until Valid Until Time PRC I.D No. 0295145 PNA No. Date document is signed:

__
PRC I.D. No. PNA No. Date document is signed:
. . Time__ _____________
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

IMMEDIATE NEWBORN CORD CARE in Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ____________________________________ Signature of Student


Indicate where performed e.g. D.R., Nursery, NICU, or Home
D.R. Nurse / Midwife On Duty (Name only)

PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Please specify Highest Nursing Degree Earned:
Concurred by:
__
Approved by:
ADPCN No. 0396 Valid Until April 2011 Date document is signed: Time____________________

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ODC Form 1 O.R.

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

Date Performed and Time Started 8-24-2010 9:00 a.m.

O.R. Nurse On Duty (Name only) Regine Ong-iko,RN

SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva,RN,MAN

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

Valid until Lifetime . Time____________________ .

ODC Form 1 O.R. SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

Prepared by: Name of Student __Jane O. Pareja____________________________ ____________________________________

Date Performed and Time Started 06-28-2010 10:50 a.m.

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva,RN, MAN

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

Valid until Lifetime . Time____________________ .

ODC Form 1 O.R. SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

Date Performed and Time Started 07-04-2010 11:56 a.m.

O.R. Nurse On Duty (Name only) Raymond ChrisTa-A RN,RM

SUPERVISED BY Clinical Instructor Name and Signature Jennifer T. Navarro,RN,MAN

11-13-2010 9:44 a.m.

Charles Jayson Carino 66985

Noted by: Chief Nurse

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

Valid until Lifetime . Time____________________ .

ODC Form 1 O.R. SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

Date Performed and Time Started 05-04-2010 3:25 p.m.

O.R. Nurse On Duty (Name only) Perpetua Liwanag,RN

SUPERVISED BY Clinical Instructor Name and Signature Aldalyn Datul,PTRP,RN,MAN

Noted by: Chief Nurse

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

Please specify Highest Nursing Degree Earned: Approved by:

ODC Form 1 O.R. SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

SURGICAL SCRUB (Major) Jane O. Pareja

Concepcion District Hospital, Concepcion , Tarlac Hospital, Municipal/City/Province Signature of Student

Prepared by: Name of Student ______________________________ ____________________________________

Date Performed and Time Started 05-04-2010 3:25 p.m.

O.R. Nurse On Duty (Name only) Perpetua Liwanag,RN

SUPERVISED BY Clinical Instructor Name and Signature Aldalyn Datul,PTRP,RN,MAN

Celia Laberinto, RN,MAN

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

ZENY C. MINA, R.N., MAN Dean

Valid until Lifetime . Time____________________ .

ODC Form 1 O.R. SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

SURGICAL SCRUB in (Major)

Hospital, Municipal/City/Province Signature of Student

Prepared by: Name of Student ______________________________ ____________________________________

Date Performed and Time Started

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Chief Nurse

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

ODC Form 1 O.R. SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

Date Performed and Time Started 08-16-2010 2:05p.m.

O.R. Nurse On Duty (Name only) Rose Ann Yambao,RN

SUPERVISED BY Clinical Instructor Name and Signature Melissa Caliva, RN,MAN

08-16-2010 5:37 p.m.

Jayson Rasqueta 10-2776

Manuel Almelor ,MD, RN,MAN Chief Nurse

JONATHAN R. YANEZA, R.N., MAN Clinical Coordinator

Prepared by: Name of Student Jane O. Pareja __________

Prepared by: Name of Student ______

Prepared by: Name of Student ______

Prepared by: Jane O. Pareja Name of Student ______