OR Form 1A

O.R. SCRUB FORM

Major
NOTRE DAME OF TACURONG COLLEGE
LAPU-LAPU ST., TACURONG CITY, SULTAN KUDARAT
PHONE #: (064)200-3631 / FAX #: (064)200-4131
If Accredited: N/A

SURGICAL SCRUB in SOUTH COTABATO PRVINCIAL HOSPITAL, Koronadal City, South Cotabato
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student: ELOSO, QUEZALYN PASCUAL

Date Performed Patients INITIALS SUPERVISED BY

O.R. Nurse On Duty
and (only) SURGICAL PROCEDURE Clinical Instructor
(Name and Signature)
Time Started Case Number PERFORMED Name and Signature

November 14, 2010 MJ.L.F. Appendectomy ( Midline ) Neil E. Cueva, RN Shangrila Joy V. Ancheta, RN, MN
11:38 in the evening 32-35-01 Lavage PRC I.D. No.: 0503748 PRC I.D. No.: 0336657

Noted by: Approved by:

SUSAN LOVE A. PEREGRINO, RN, MN JOELARGEN G. ARADANAS, MN, MAN

Clinical Coordinator Dean
PRC I.D. No.: 0322547 Valid Until: October 20, 2013 PRC I.D. No.: 0330706 Valid Until: September 13, 2012
PNA No.: 19142 Valid Until: Life Member PNA No.: 030642 Valid Until: October 31, 2011
Date Signed: ____________________ Time: ________ ADPCN No.: 18759 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Masters in Nursing Date Signed: _____________Time: ____________________
Highest Nursing Degree Earned: Master of Arts in Nursing