General guidelines for signing of templates: 1. Mount all your case slips in long bond paper . Chronologically arranged.

2. Accomplish templates (see samples below). Take note of the following: a. 1 template per institution; if cases were all accomplish in 1 institution, you can put all cases in one template aslong as it can be accommodated in 1 page. If not then make another template. b. There are no case numbers for the following: ITR well baby, cases taken at ER,OPR,Minor OR of hospitals and community cases and medical-surgical mission cases. The college takes the responsibility of forwarding the certification to PRC that these cases do not bear any case number. Therefore, there is no need for you to get certification from the different institutions. c. For medical mission cases, the CI supervising signs both item for CI and Staff nurse. d. For cases accomplished during completion duty at slu and bmc without a CI, Mrs. Cherrylina Dalilis is place at the item CI and signs for that case. e. Cases are to be written in chronological order. First case to latest. 3. Proceed with the processing of signing of your templates by the CI and staff nurses. 4. Safe keep all accomplished templates.

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ODC Form 1A ACTUAL DELIVERY FOR

Comment [p1]: GENERAL INSTRUCTIONS: 1. ALL TEMPLATES SHOULD BE IN DUPLICATE COPY. 1 for PRC, 1 for student. ALL Original. Provide 1 photocopy for school copy. 2. For Staff Nurse or CIs who have resigned, the authorization letter (secured from DH) signed by the chief nurse of the institution designating the signatory in behalf of the resigned staff should be attached to the template (PRC copy only) 3. For medical Mission cases: attach certification from college to the template. (secured from DH)

ACTUAL DELIVERY in : Abra Provincial Hospital, Bangued, Abra

Hospital, Municipality, Province Prepared by: QUITALIG, ELVIS DE LA RAGA
Date Performed And Time Started Patients Initials Case Number D.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature
Comment [p2]: Identify only those which are applicable. Items separated by commas. Examples:if Baguio General Hospital and Medical Center, Baguio City; only hospital and city are identified For LUMC : hospital, municipality and Province For ITR: Hospital, City and Province For SLU-SHS, BMC: hospital & City

PROCEDURE PERFOR ED

02-13-10 2:46 PM

A.B. 892490

Normal Spontaneous Delivery

Marie Jane Bernardez, RN

Estrella Leviste, RN

For BeGH: Hospital, Municipality, Province For home delivery: see notation below template For Medical Mission: See notation below temp[late for minor cases Comment [p3]: If case has been assisted by a midwife (for Kalinga cases).The Headnurse/staff nurse of the units name should still be the name that will appear on the template Comment [p4]: Regardless of degree, only RN is placed at the names of CI or Staff nurses who assisted the student. MAN or MSN are never placed.

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: ARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11 -10-2013 PNA No: 9860 V until: LIFETIME alid ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

Comment [p5]: ADPCN not ADCPN

Note: For Home delivery:

Actual Delivery in: Lengaoan, Buguias, Benguet (Home Delivery) Community, Municipal, Province
Comment [p6]: For cases which are delivered at home, please follow this label

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ODC Form 1B ASSISTED DELIVERY FOR

ASSISTED DELIVERY in : Ilocos Training and Regional Medical Center, City of San Fernando, La Union
Hospital, City, Province Prepared by: QUITALIG, ELVIS DE LA RAGA
Date Performed And Time Started Patients Initials Case Number PROCEDURE PERFOR ED ASSISTED DELIVERY D.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Comment [p7]: Take note, its City of San Fernando NOT San Fernando City.

12-12-09 11:10 PM 12-27-09 2:40 PM

A. P. 2009-0030928 G. A. 2009-0031553

Normal Spontaneous Delivery

Roni Joyce Novillero, RN

Charmaine Co, RN

Comment [p8]: Not limited to 2 letters. If client has 2 names then: M.T.P (Maria Teresa Pascua) if with Jr (Andres Paolo Aquin, Jr.)= A.P.A., Jr. Comment [p9]: If no middle initial has been place in the name of all RN, please be consistent-no middle initial in all entries Comment [p10]: Should be chronologically arranged.

Normal Spontaneous Delivery

Marjorie Navalta,RN

Blas Blasil Purganan, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: ARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ODC Form 1C CORD CARE FOR

EDIATE NEWBORN CORD CARE in : Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, City

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed And Time Started Patients Initials Case Number Immediate Newborn Cord Care PERFOR ED Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature
Comment [p11]: Take note: Nurse on duty, not OR or DR nurse.

04-28-09 9:30 PM

B.B.P. PB363215

Cord Care - Nursery

Wendy Villareal, RN

Felda Ibasitas, RN

Comment [p12]: Place where cord care has been accomplished are specifies. If cord care has been executed in a lying in clinic, it has to be identified. If hom,e, place home

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: ARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12 -31-2011 Date signed: __________________ Time: ______________

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ODC Form 2A O.R. SCRUB FORM Major

SURGICAL SCRUB in: Benguet General Hospital, La Trinidad, Benguet

Hospital, Municipality, Province Prepared by: QUITALIG, ELVIS DE LA RAGA
Date Performed And Time Started Patients Initials Case Number O.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature
Comment [p13]: One template should be accomplished for each institution. If OR cases has been finished in 5 institutions, accomplish 5 templates for OR major. Comment [p14]: Signature of students should be on top.

SURGICAL PROCEDURE PERFOR

ED

06-09-09 4:27 PM

S.D. 241175

Emergency Low Segment Cesarean Section and Bilateral Tubal Ligation

Frederick Gabriel, RN

Genevieve Pablito, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: ARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12 -31-2011 Date signed: __________________ Time: ______________

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ODC Form 2B O.R. INOR FOR

SURGICAL SCRUB in: Baguio Medical Center, Baguio City

Hospital, City Prepared by: QUITALIG, ELVIS DE LA RAGA
Date Performed And Time Started Patients Initials Case Number O.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature
Comment [p15]: Change place of completion as applicable

SURGICAL PROCEDURE PERFOR

ED

04-14-09 3:05 PM 10-21-09 10:34 AM

J.G. 11711434 M. D. 442

Cervical Biopsy and Diagnostic Dilation and Curettage

Chiara Rene Barcelo, RN

Lawrence Gayo, RN

Excision of Lipoma

Maria Olivia Daag, RN

Cherylina Dalilis, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: ARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12 -31-2011 Date signed: __________________ Time: ______________

Note: if case was accomplished in a medical mission:pls follow the ff format for title SURGICAL SCRUB in: Sanitary Camp Health Center, Baguio City (Medical Mission sponsored by Rotary Club of Baguio) Barangay, City, Sponsoring Agency

Comment [p16]: Comment [p17]: Take note

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ODC Form 2C O.R. CIRCULATING

O.R. CIRCULATING in: Baguio Medical Center Baguio City

Hospital, City Prepared by: QUITALIG, ELVIS DE LA RAGA
Date Performed And Time Started Patients Initials Case Number O.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Comment [p18]: To complete 5 cases either major or minor

SURGICAL PROCEDURE PERFOR

ED

06-16-09 3:35 PM

R. B. 11711440

Completion Curettage

Vannesa Canillas, RN

Lawrence Gayo, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: ARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12 -31-2011 Date signed: __________________ Time: ______________