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Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: TORIO, Melvyn G First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program: June2005 2011
University Seal
I. MAJOR OPERATIONS
No. DATE of OPERATION July 11, 2011 1 TIME of OPERATION STARTEDENDED 10:25 AM 10:40 AM PATIENTS INITIALS CASE NO. J.A.R 53291 Three Centimeters Lacerated Wound, Parietal Area DIAGNOSIS OPERATION PERFORMED Suturing & Dressing TYPE of ANESTHESIA Lucal Anesthesia NAME of SURGEON Dr. Jolad Daguro NAME of HOSPITAL MCH
Name & Signature of Qualified Clinical Instructor
Stephane E. De Vera
Prepared by:
Supervised by: Date signed: Degree: PRC I.D. No.: PNA No.:
STEPHANE E. DE VERA
Clinical Instructor B.S.N R.N, RM 0426035 Valid Until: May 06, 2013 040477 Valid Until: October 31, 2011
Noted by:
ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2014 PNA No.: 040412 Valid Until: October 31, 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: MAN, EdD
Approved by:
MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 09, 2013 PNA No.: 040351 Valid Until: October 31, 2011 ADPCN No.: 11260 Valid Until: May 31, 2012 Date document is signed: Time: Please specify Highest Nursing Degree Earned: MAN
University Seal
Local anesthesia
2 3
R1MC R1MC
LEGEND:
Concurred by:
R1MC, Chief Nurse PRC I.D. No.: 46196 Valid Until: February 03, 2011 PNA No.: 2401 Valid Until: Lifetime Member ANSAP No.: 0106 Valid Until: Lifetime Member Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.S.N
Supervised by: Date signed: Degree: PRC I.D. No.: PNA No.:
JEFFERSON P. PEDUCA Clinical Instructor July 29, 2010 BSN RN, RM 0379703 Valid Until: October 07, 2011 01379 Valid Until: October 31, 2010
Noted by:
PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 013926 Valid Until: October 31, 2010 Date document is signed: 2011 - 040412 Time: Please specify Highest Nursing Degree Earned: M.A.N
Approved by:
PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 09, 2013 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: 19482 Valid Until: May 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.A.N
University Seal
III.
No. 1 2 3 4 5 LEGEND: Prepared by: Student
Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until: Noted by:
ACTUAL DELIVERIES
TIME of DELIVERY GENDER of BABY TYPE of DELIVERY NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor
DIAGNOSIS
AGE
DATE of DELIVERY
Concurred by: Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: Date document Time: Approved by: is signed: MARIA TERESA R. FAJARDO PROF. Please specify Highest Nursing Degree Earned: Dean PRC I.D. No.: 0160104 Valid Until: September 9, 2010 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned:
PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please specify Highest Nursing Degree Earned:
University Seal
IV.
No. 1 2 3 4 5 LEGEND: DIAGNOSIS MOTHERS INITIALS CASE NO. AGE DATE of DELIVERY
ASSISTED DELIVERIES
TIME of DELIVERY GENDER of BABY TYPE of DELIVERY NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor
Concurred by: Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: Date document is signed: Please specify Highest Nursing Degree Earned:
Time:
Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:
Noted by:
PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please specify Highest Nursing Degree Earned:
Approved by:
PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 9, 2010 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned:
Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: ROSALES, Johnedel Mendoza First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program: June2005 2011
University Seal
Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN
Concurred by:
TPH, Chief Nurse PRC I.D. No.: 46196 Valid Until: February 03, 2011 PNA No.: 2401 Valid Until: Lifetime Member ANSAP No.: 0106 Valid Until: Lifetime Member Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.S.N Approved by: PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 09, 2013 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: 19482 Valid Until: May 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.A.N