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Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Tel. No. (02)859-0812/ Fax No.

(02) 859-0875 PAASCU Level II Re-Accredited Status, November 2011 - November 2016
SURGICAL SCRUB IN JUSTICE JOSE ABAD SANTOS GENERAL HOSPITAL Hospital, Municipality/City/Province

O.R. Form 1A
Prepared by: Printed Name with Signature of Student: VANESSA KYLA C. UMITEN
Date Performed and Time Started Patients INITIAL (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)
O.R. SCRUB FORM Major

SUPERVISED BY: Clinical Instructor Name and Signature

JULY 13, 2012 10:45 am

R.L.M 552448

ELECTIVE FUNCTIONAL ENDOSCOPIC SINUS SX

MARIE KATHLEEN D. CASTRO, RN

SHIELA S. TORRES RN, MAN

O.R. Form 1A
Prepared by: Printed Name with Signature of Student _______________________________________________
Date Performed and Time Started Patients INITIAL (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)
O.R. CIRCULATING FORM

SUPERVISED BY: Clinical Instructor Name and Signature

(STRICTLY NO DESIGNATES) (This Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN)

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Tel. No. (02)859-0812/ Fax No. (02) 859-0875 PAASCU Level II Re-Accredited Status, November 2011 - November 2016
ACTUAL DELIVERY IN ______________________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province D.R. FORM
ACTUAL DELIVERY FORM

Prepared by: Printed Name with Signature of Student _______________________________________________


Date Performed and Time Started Patients INITIAL (only) Case Number (not applicable for
Birthing/Lying-in Clinics/Home)

PROCEDURE PERFORMED

D.R. Nurse on Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

IMMEDIATE NEWBORN CORD CARE IN ______________________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province ICNB FORM Prepared by: IMMEDIATE CARE OF THE NEWBORN FORM Printed Name with Signature of Student _______________________________________________
Date Performed and Time Started Patients INITIAL (only) Case Number (not applicable for
Birthing/Lying-in Clinics/Home)

IMMEDIATE NEWBORN CORD CARE PERFORMED


Performed e.g. DR, Nursery , NICU Or Home

D.R. Nurse on Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

(STRICTLY NO DESIGNATES) (This Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN)