Republic of the Philippines

Mountain Province State Polytechnic College

Bontoc, Mountain Province

ODC Form 2A
OR SCRUB FORM

SURGICAL SCRUB in
BONTOC GENERAL HOSPITAL/ BONTOC MOUNTAIN PROVINCE /BAGUIO GENERAL HOSPITAL &
MEDICAL CENTER/ BAGUIO CITY
Hospital, Municipality/City/Province
Prepared by: Printed Name with Signature of Student

Date Performed
and
Time Started

Patients INITIALS
(only)
Case Number

12-08- 2012
3:44PM

A.B
3445

02-28-2013
9:50am

L.Q.
678364

03-01-2013
2:42pm.

D. A.
679507

DEPIA LEAH O. NGISLAWAN________________________

SURGICAL PROCEDURE
PERFORMED
Cholecystectomy
TAHBSO IO PHC, ADHESIOLYSIS
LND, Left
SUPERFICIAL PAROTIDECTOMY
with DISSECTION &
PRESERVATION of CN VII

Noted by: _______________________________________________

Clinical Coordinator,

(Print Name and Signature)

PRC I.D No. ________________ Valid Until ____________ ______

Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

HEATHER HASMIN A.
MOCYAT

FLORITA A. SACGACA

JAIME W. REYES
STEVE C. CATACUTAN

ETHELBERT BANDAS

Approved by: ___________________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

Republic of the Philippines

Mountain Province State Polytechnic College
Bontoc, Mountain Province

SURGICAL SCRUB in

ODC Form 2B
OR SCRUB FORM

________________________________________________________________________
Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student DEPIA LEAH O. NGISLAWAN____________________

Date Performed
and
Time Started

Patients INITIALS
(only)
Case Number

SURGICAL PROCEDURE
PERFORMED

Noted by: _______________________________________________

(Print Name and Signature)

Clinical Coordinator,

PRC I.D No. ________________ Valid Until ____________ ______

Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor Name
and Signature

Approved by: ___________________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

Republic of the Philippines

Mountain Province State Polytechnic College
Bontoc, Mountain Province

ODC Form 1A
ACTUAL DELIVERY
FORM

ACTUAL DELIVERY in BAGUIO GENERAL HOSPITAL & MEDICAL CENTER/ BAGUIO CITY/ BONTOC GENERAL HOSPITAL/
BONTOC MOUNTAIN PROVINCE
Hospital, Home, Lying-In Clinic,
Municipality/City/Province
Prepared by: Printed Name with Signature of Student _DEPIA LEAH O. NGISLAWAN________________

Patients INITIALS
(only)
Case Number

PROCEDURE PERFORMED

D.R. Nurse On Duty

(Name and Signature)

02- 19- 2013

10:49am

M.C.F
681200

Normal Spontaneous
Delivery

MICHELLE L. SUYAT

ZUBAIDA P.
ASTUDILLO

02-23- 2013
12:36am
03- 12- 2013
7:42am

C. C. G.
378577
R.K
2973

Normal Spontaneous
Delivery
Normal Spontaneous
Delivery

DAISY M. GODDA

ELENA A. TAL-UDAN

IMELDA C. SAWI

FLORITA A. SACGACA

Date Performed
and
Time Started

(not applicable for

Birthing/Lying-In
Clinics/Homes)

Noted by: _______________________________________________

(Print Name and Signature)
Clinical Coordinator,

PRC I.D No. ________________ Valid Until ____________ ______

Date document is signed: _________________________ Time __________________
Please specify Highest Nursing Degree Earned: _______________________________

(If Midwife on Duty,

Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: ___________________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________
Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

Republic of the Philippines

Mountain Province State Polytechnic College
Bontoc, Mountain Province
IMMEDIATE NEWBORN CORD CARE in

ODC Form 1B
IMMEDIATE NEWBORN
CORD CARE FORM

LUIS HORA MEMORIAL REGIONAL HOSPITAL/ ABATAN BAUKO MOUNTAIN

PROVINCE/
BAGUIO GENERAL HOSPITAL & MEDICAL CENTER/ BAGUIO CITY
Hospital, Home, Lying-In Clinic Municipality/City/Province

Prepared by: Printed Name with Signature of Student __ DEPIA LEAH O. NGISLAWAN_____________________

Date Performed
and
Time Started

Patients
INITIALS (only)
Case Number
(not applicable for
Birthing/Lying-In
Clinics/Homes)

IMMEDIATE NEWBORN CORD

CARE PERFORMED
Indicate where performed
e.g. D.R., NURSERY, NICU, or
HOME

07- 16- 2012

05:58pm

Bb. D.
056228

NURSERY

02- 22- 2013

10:26pm.

C.F.B
682009

NURSERY

02- 23- 2013

7:31pm

C.B.D.L
681994

NURSERY

Noted by: _______________________________________________

Clinical Coordinator,

(Print Name and Signature)

PRC I.D No. ________________ Valid Until ____________ ______

Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARCELINA CAWALO

MARIBETH ANN T.
BILLAO

KATRINA D. DOMINGO

MAUREEN D.
BARTOLOME

KATRINA D. DOMINGO

MAUREEN D.
BARTOLOME

Approved by: ___________________________________________________

(Print Name and Signature)
Dean, PRC I.D. No. ____________________ Valid Until __________________________

Date document is signed: _________________________ Time __________________

Please specify Highest Nursing Degree Earned: _______________________________

Date document is signed: ______________________ Time: _______________________

Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)