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ODC Form 1A

ACTUAL DELIVERY FORM


Republic of the Philippines
Professional Regulation Commission
Board of Nursing

SOUTHWESTERN UNIVERSITY
College of Nursing
Villa Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email Address: swu.nursing@gmail.com

ACTUAL DELIVERY in Sacred Heart Hospital


Hospital / Home / Lying-In Clinic, Municipality / City / Province

Prepared by:
Printed Name and Signature of Student Juan Santos dela Cruz

Patient’s INITIAL (only)


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

April 23. 2010 G.J.M Normal Spontaneous


6:19 PM 089264 Vaginal Delivery Mrs. Teresita M. Nacua Mrs. Corazon B. Dumadag, RN MAN

Noted by: RAMON PERLEY M. PANDAAN Approved by: LUCRIS A. TAN JR.
OR/DR Clinical Coordinator, PRC I.D. No. 0243199 Valid Until July 8, 2010 Dean, PRC I.D. No. 0285376 Valid Until April 9, 2012
Date document is signed:________Time____________ Date document is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MD, MAN

(STRICTLY NO DESIGNATES)
ODC Form 2A
O.R. SCRUB FORM
Republic of the Philippines Major
Professional Regulation Commission
Board of Nursing

SOUTHWESTERN UNIVERSITY
College of Nursing
Villa Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email Address: swu.nursing@gmail.com

SURGICAL SCRUB in _______________________________________________________________________


Hospital, Municipality / City / Province

Prepared by:
Printed Name and Signature of Student ______________________________________

Date Performed SUPERVISED BY


Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty
and Clinical Instructor
PERFORMED (Name AND Signature)
Time Started Name and Signature
Case Number

Noted by: RAMON PERLEY M. PANDAAN Approved by: LUCRIS A. TAN JR.
OR/DR Clinical Coordinator, PRC I.D. No. 0243199 Valid Until July 8, 2010 Dean, PRC I.D. No. 0285376 Valid Until April 9, 2012
Date document is signed:________Time____________ Date document is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MD, MAN

(STRICTLY NO DESIGNATES)
ODC Form 1B
Republic of the Philippines ASSISTED DELIVERY FORM
Professional Regulation Commission
Board of Nursing

SOUTHWESTERN UNIVERSITY
College of Nursing
Villa Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email Address: swu.nursing@gmail.com

ACTUAL DELIVERY in _______________________________________________________________________


Hospital / Home / Lying-In Clinic, Municipality / City / Province

Prepared by:
Printed Name and Signature of Student ______________________________________

Patient’s INITIAL only PROCEDURE


Date Performed D.R. Nurse/Midwife On Duty SUPERVISED BY
PERFORMED
and (Name and Signature) Clinical Instructor
Time Started Name and Signature
Case Number ASSISTED DELIVERY

Noted by: RAMON PERLEY M. PANDAAN Approved by: LUCRIS A. TAN JR.
OR/DR Clinical Coordinator, PRC I.D. No. 0243199 Valid Until July 8, 2010 Dean, PRC I.D. No. 0285376 Valid Until April 9, 2012
Date document is signed:________Time____________ Date document is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MD, MAN

(STRICTLY NO DESIGNATES)
Republic of the Philippines ODC Form 2B
Professional Regulation Commission O.R. SCRUB MINOR
Board of Nursing

SOUTHWESTERN UNIVERSITY
College of Nursing
Villa Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email Address: swu.nursing@gmail.com

SURGICAL SCRUB in _______________________________________________________________________


Hospital, Municipality / City / Province

Prepared by:
Printed Name and Signature of Student ______________________________________

Patient’s INITIAL only


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

Noted by: RAMON PERLEY M. PANDAAN Approved by: LUCRIS A. TAN JR.
OR/DR Clinical Coordinator, PRC I.D. No. 0243199 Valid Until July 8, 2010 Dean, PRC I.D. No. 0285376 Valid Until April 9, 2012
Date document is signed:________Time____________ Date document is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MD, MAN

(STRICTLY NO DESIGNATES)
ODC Form 1C
Republic of the Philippines IMMEDIATE NEWBORN CORD
Professional Regulation Commission CARE
Board of Nursing

SOUTHWESTERN UNIVERSITY
College of Nursing
Villa Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email Address: swu.nursing@gmail.com

IMMEDIATE NEWBORN CORD CARE in _______________________________________________________________________


Hospital / Home / Lying-In Clinic, Municipality / City / Province

Prepared by:
Printed Name and Signature of Student ______________________________________

Patient’s INITIAL only Immediate Newborn Cord Care


Date Performed D.R. Nurse/Midwife On Duty SUPERVISED BY
PERFORMED
and (Name and Signature) Clinical Instructor
Indicate where performed e.g. D.R.,
Time Started Name and Signature
Case Number Nursery, NICU, or Home

Noted by: RAMON PERLEY M. PANDAAN Approved by: LUCRIS A. TAN JR.
OR/DR Clinical Coordinator, PRC I.D. No. 0243199 Valid Until July 8, 2010 Dean, PRC I.D. No. 0285376 Valid Until April 9, 2012
Date document is signed:________Time____________ Date document is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MD, MAN
(STRICTLY NO DESIGNATES)

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