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UNIVERSITY OF PANGASINAN
PHINMA Education Network
College of Nursing Name of Patient: Name of Patient:
Dagupan City
___________________________________________ ___________________________________________
ACTUAL CASE SLIP Address: ___________________________________ Address: ___________________________________
Age: _______________ Case No: _______________ Age: _______________ Case No: _______________

NAME OF STUDENT: Gravida: ____________ Para: __________________ Gravida: ____________ Para: __________________
Date of Delivery: ____________________________ Date of Delivery: ____________________________
Gender of Baby: _____________________________ Gender of Baby: _____________________________
Time of Delivery: ____________________________ Time of Delivery: ____________________________
STUDENT NUMBER:
___________________________________________ Type of Delivery: ____________________________ Type of Delivery: ____________________________
Diagnosis: Diagnosis:

PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN ___________________________________________ ___________________________________________

CLINICAL COORDINATOR ___________________________________________ ___________________________________________


___________________________________________ ___________________________________________
PRC NO: 0133422 . Obstetrician: ________________________________ Obstetrician: ________________________________
VALID UNTIL: July 27, 2011 .

PNA NO: . ____________________ _____________________ ____________________ _____________________


VALID UNTIL: . Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________
ANSAP NO: .
VALID UNTIL: .
Agency: Agency:
___________________________________________ ___________________________________________
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Name of Patient: Name of Patient: Name of Patient:


___________________________________________ ___________________________________________ ___________________________________________
Address: ___________________________________ Address: ___________________________________ Address: ___________________________________
Age: _______________ Case No: _______________ Age: _______________ Case No: _______________ Age: _______________ Case No: _______________
Gravida: ____________ Para: __________________ Gravida: ____________ Para: __________________ Gravida: ____________ Para: __________________
Date of Delivery: ____________________________ Date of Delivery: ____________________________ Date of Delivery: ____________________________
Gender of Baby: _____________________________ Gender of Baby: _____________________________ Gender of Baby: _____________________________
Time of Delivery: ____________________________ Time of Delivery: ____________________________ Time of Delivery: ____________________________
Type of Delivery: ____________________________ Type of Delivery: ____________________________ Type of Delivery: ____________________________
Diagnosis: Diagnosis: Diagnosis:
___________________________________________ ___________________________________________ ___________________________________________
___________________________________________ ___________________________________________ ___________________________________________
___________________________________________ ___________________________________________ ___________________________________________
Obstetrician: ________________________________ Obstetrician: ________________________________ Obstetrician: ________________________________

____________________ _____________________ ____________________ _____________________ ____________________ _____________________


Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________

Agency: Agency: Agency:


___________________________________________ ___________________________________________ ___________________________________________
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UNIVERSITY OF PANGASINAN
PHINMA Education Network
College of Nursing Name of Patient: Name of Patient:
Dagupan City
___________________________________________ ___________________________________________
ASSISTED CASE SLIP Address: ___________________________________ Address: ___________________________________
Age: _______________ Case No: _______________ Age: _______________ Case No: _______________

NAME OF STUDENT: Gravida: ____________ Para: __________________ Gravida: ____________ Para: __________________
Date of Delivery: ____________________________ Date of Delivery: ____________________________
Gender of Baby: _____________________________ Gender of Baby: _____________________________
Time of Delivery: ____________________________ Time of Delivery: ____________________________
STUDENT NUMBER:
___________________________________________ Type of Delivery: ____________________________ Type of Delivery: ____________________________
Diagnosis: Diagnosis:

PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN ___________________________________________ ___________________________________________

CLINICAL COORDINATOR ___________________________________________ ___________________________________________


___________________________________________ ___________________________________________
PRC NO: 0133422 . Obstetrician: ________________________________ Obstetrician: ________________________________
VALID UNTIL: July 27, 2011 .

PNA NO: . ____________________ _____________________ ____________________ _____________________


VALID UNTIL: . Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________
ANSAP NO: .
VALID UNTIL: .
Agency: Agency:
___________________________________________ ___________________________________________
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Name of Patient: Name of Patient: Name of Patient:


___________________________________________ ___________________________________________ ___________________________________________
Address: ___________________________________ Address: ___________________________________ Address: ___________________________________
Age: _______________ Case No: _______________ Age: _______________ Case No: _______________ Age: _______________ Case No: _______________
Gravida: ____________ Para: __________________ Gravida: ____________ Para: __________________ Gravida: ____________ Para: __________________
Date of Delivery: ____________________________ Date of Delivery: ____________________________ Date of Delivery: ____________________________
Gender of Baby: _____________________________ Gender of Baby: _____________________________ Gender of Baby: _____________________________
Time of Delivery: ____________________________ Time of Delivery: ____________________________ Time of Delivery: ____________________________
Type of Delivery: ____________________________ Type of Delivery: ____________________________ Type of Delivery: ____________________________
Diagnosis: Diagnosis: Diagnosis:
___________________________________________ ___________________________________________ ___________________________________________
___________________________________________ ___________________________________________ ___________________________________________
___________________________________________ ___________________________________________ ___________________________________________
Obstetrician: ________________________________ Obstetrician: ________________________________ Obstetrician: ________________________________

____________________ _____________________ ____________________ _____________________ ____________________ _____________________


Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________

Agency: Agency: Agency:


___________________________________________ ___________________________________________ ___________________________________________