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SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City


(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016
D.R. Form

ACTUAL DELIVERY FORM

ACTUAL DELIVERY In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature

Date Performed Patients INITIALS SUPERVISED BY


PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

April 29, 2016 JC


Normal Spontaneous Delivery
3:49 PM CG401244
Zhyra Gail Ducusin Maria Linda Guitang-na
SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City ICNB Form
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 IMMEDIATE CARE
FAX: (074) 442-2842 OF THE NEWBORN

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

IMMEDIATE NEWBORN CARE In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature

Date Performed Patients INITIALS SUPERVISED BY


PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

November 7, 2015 BM
Cord Care
3:31 PM MB400968
Lexie Luis Maria Linda Guitang-na
O.R. Form 1A
O.R. SCRUB FORM
Major
SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

MAJOR SURGICAL SCRUB In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature

Date Performed Patients INITIALS SUPERVISED BY


PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature
October 8, 2016 JB
Repeat Cesarean Section
7:12 AM N46667 Kathleen Guevarra
Caesar Labon

February 28, 2017 SD Open Cholecystectomy lavage,


9:07 AM N47900 placement of drain Karl Christian Golucan
Daisyree Gines
Exploratory Laparotomy,
June 2, 2017 FS
Sigmoidectomy, Cholecystectomy,
7:24 AM N48692 Rosemarie Pachao
Excision of Peritoneal Cyst Katrina Gonzales O.R. Form 1A
O.R. SCRUB FORM
Minor

SAINT LOUIS UNIVERSITY


A. Bonifacio Street, 2600 Baguio City
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

MINOR SURGICAL SCRUB In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature


Date Performed Patients INITIALS SUPERVISED BY
PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

February 27, 2017 RN


Laparascopic Cholecystecotmy
10:58 AM N46650 Karl Christian Golucan
Maria Angelica de Sahagun

October 14, 2016 AT


Ventriculoperitoneal Shunt Revision
8:41 AM N46714 Kathleen Gail Guevarra
Caesar Labon
O.R. Form 1A
O.R. SCRUB FORM
June 2, 2017 FS Incisional Hernia Repair, Partial
Minor
7:24 AM N48693 Omentectomy Rosemarie Pachao
Katrina Gonzales

SAINT LOUIS UNIVERSITY


A. Bonifacio Street, 2600 Baguio City
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

MINOR SURGICAL SCRUB In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature


Date Performed Patients INITIALS SUPERVISED BY
PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

October 6, 2016 SG Excision biopsy of Bilateral Breast


8:33 AM N46714 Mass
Cristy Guidangen Kathleen Gail Guevarra

October 14, 2016 AT


Ventriculoperitoneal Shunt Revision
8:41 AM N46714
Caesar Labon Kathleen Gail Guevarra

February 20, 2016 LR


Upper and Lower Blepharoplasty
11:12 AM N47822
Katrina Gonzales Karl Christian Golucan
SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016 O.R. Form 1A
O.R. SCRUB FORM
Minor

MINOR SURGICAL SCRUB In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature

Date Performed Patients INITIALS SUPERVISED BY


PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

October 6, 2016 SG Excision Biopsy of Bilateral Breast


8:33 AM N46650 Mass
Cristy Guidangen Kathleen Gail Guevarra

October 14, 2016 AT


Ventriculoperitoneal Shunt Revision
8:41 AM N46714
Caesar Labon Kathleen Gail Guevarra
February 20, 2017 LR Blepharoptosis, Blepharochalasia
11:12 AM N47822 Bilateral Karl Christian Golucan
Katrina Gonzales

SAINT LOUIS UNIVERSITY


A. Bonifacio Street, 2600 Baguio City O.R. Form 1B
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 O.R. CIRCULATING
FAX: (074) 442-2842 FORM

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

SURGICAL CIRCULATING In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature

Date Performed Patients INITIALS SUPERVISED BY


PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

February 22, 2017 JL


Hemorrhoidectomy
9:04 AM N47844
Nathalie Loreto Karl Christian Golucan
February 27, 2017 ER Tympanostomy with Ventilation tube
8:15 AM N47878 insertion, Left Karl Christian Golucan
Cristy Guidangen

O.R. Form 1B
O.R. CIRCULATING
FORM
SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City
(074) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842

Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

SURGICAL CIRCULATING In: SAINT LOUIS UNIVERSITY HOSPITAL OF THE SACRED HEART, BAGUIO CITY
Hospital, Municipality/City/Province

Prepared by: MACABONTOC, LAVENIA POSIDIO

Printed Name with Signature

Date Performed Patients INITIALS SUPERVISED BY


PROCEDURE D.R. Nurse On Duty
And Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature
Re-operation, Adhesiolysis
October 6, 2016 AB
Intraoperative Cholangiogram,
9:37 AM N46657
Hepatico-jejunostomy, Drain Placement Caesar Labon Kathleen Gail Guevarra

February 20, 2017 AM Total Thyroidectomy including


7:18 AM N47810 substernal Thyroid
John Henry Lacson Karl Christian Golucan

February 20, 2017 RG


Repeat Low Segment Cesarean Section
3:02 PM N47825
Raymond Aoay Karl Christian Golucan