OR Form 1B O.

R SCRUB FORM Major

COLLEGE OF NURSING

ACCREDITED BY: Accrediting Agency of Chartered Colleges and Universities in the Philippines Level I August, 2010 Prepared by: JUAN DELA CRUZ
Date Performed and Time Started

SURGICAL SCRUB IN GENERAL EMILIO AGUINALDO MEMORIAL HOSPITAL Trece Martires City, Cavite
Patients INITIALS Case Number M.V.C. SURGICAL PROCEDURE PERFORMED O.R Nurse On Duty SUPERVISED BY Clinical Instructor

December 27, 2011 10:30 am 214923

Total Abdominal Hysterectomy; Appendectomy

Yasser Dela Cruz, RN

EVELYN M. DEL MUNDO, RN, MAN PRC No.: 0130620 Valid until: June 12, 2012 PNA: 2012-023204 Valid until: October 31, 2012 Date signed:_________________

SURGICAL SCRUB IN BATANGAS REGIONAL HOSPITAL Batangas City, Batangas

Date Performed and Time Started Patients INITIALS

Case Number
V.B

SURGICAL PROCEDURE PERFORMED

O.R Nurse On Duty

SUPERVISED BY Clinical Instructor

March 3, 2012 1:20 am

Low Segment Cesarean Section

Mary Sherry Joy Villanueva, RN

358272

NENITA B. PANALIGAN, RN, MAN PRC I.D No.: 0201832 Valid Until: March 01, 2012 PNA No.:2012- 023203 Valid Until: October 31, 2012 Date signed:_________________

SURGICAL SCRUB IN KOREA-PHILIPPINES FRIENDSHIP HOSPITAL Trece Martires City, Cavite

Date Performed and Time Started Patients INITIALS Case Number B.M.D. March 16, 2012 9:08 am Cholecystectomy Henson Maranan, RN LETICIA M. DEL ROSARIO, RN, MAN PRC No.:0110878 Valid until: March 8, 2014 PNA No.:18655 Valid until: October 31, 2012 Date Signed: _________________ SURGICAL PROCEDURE PERFORMED O.R Nurse On Duty SUPERVISED BY Clinical Instructor

219175