O.R.

Form 1A
O.R. SCRUB FORM
Major
ATENEO DE ZAMBOANGA UNIVERSITY
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
SURGICAL SCRUB in ZAMBOANGA DOCTORS HOSPITAL,INC., ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: PASTOR, CHERUBIM FAITH ENRIQUEZ Signature of Student__________________________

Date Performed Patients Name SURGICAL PROCEDURE O.R. Nurse On Duty

SUPERVISED BY:
and Clinical Instructor
PERFORMED Name and Signature
Time Started Name and Signature
Case Number

September 11, 2017 E.C.J. Open reduction with internal fixation, Kim Irish Lee, RN
Eva R. Relao, RN MN
1:57 PM 68217 lateral pinning distal humerus left

Noted by: Approved by:

JOSEPHINE JUDITH PERANO-ALFORTE, RN, MN MARIA LORNA BELLO-PABER, RN, MAN
Clinical Coordinator Dean
PRC I.D. No. 0112157 Valid Until: 2016 PRC I.D. No. 0059150 Valid Until: 2019
PNA I.D. No. Valid Until: PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2017

Date document is signed: _______________________ Time: ______________ Date document is signed: ________________________ Time: __________
Highest Degree Earned: MASTERS IN NURSING Highest Degree Earned: MASTER OF ARTS IN NURSING
 O.R Form 1B
O.R. CIRCULATING
ATENEO DE ZAMBOANGA UNIVERSITY FORM Major
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED Accredited Level III/ Year Granted: May 20, 2014-2019
SURGICAL SCRUB in ZAMBOANGA DOCTORS HOSPITAL,INC., ZAMBOANGA CITY
Hospital, Municipality/ City/ Province

Prepared by:
Name of Student: PASTOR, CHERUBIM FAITH ENRIQUEZ Signature of Student__________________________

Date Performed Patients Name SURGICAL PROCEDURE O.R. Nurse On Duty

SUPERVISED BY:
and Clinical Instructor
PERFORMED Name and Signature
Time Started Name and Signature
Case Number

September 13, 2017 H.L.

Myomectomy Edgar Torres Jr., RN Eva R. Relao, RN MN
8:33 AM 160706

Noted by: Approved by:

JOSEPHINE JUDITH PERANO-ALFORTE, RN, MN MARIA LORNA BELLO-PABER, RN, MAN
Clinical Coordinator Dean
PRC I.D. No. 0112157 Valid Until: 2019 PRC I.D. No. 0059150 Valid Until: 2019
PNA I.D. No. Valid Until: PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2017

Date document is signed: _______________________ Time: ______________ Date document is signed: ________________________ Time: __________
Highest Degree Earned: MASTERS IN NURSING Highest Degree Earned: MASTER OF ARTS IN NURSING