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CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Address: No. 9 Mendiola St., San Miguel, ManilaTel. No.: 7356861 to 71 Loc. 219 Fax Number: 7362211
E-Mail Address:Web-Site: www.ceu.edu.ph
Accredited by: PAASCU Level II, May 13, 2011
ACTUAL DELIVERY in Dr. Jose Fabella Memorial Hospital, Ospital ng Maynila, Pasig General Hospital Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: LOMEDA, RYAN ONEIL A.
Patient's INITIAL only
PROCEDURE PERFORMED
09/15/2011 ; 3:55 am C.J. ; 419105 Normal Spontaneous Vaginal Delivery Milagros DJ. Canlas RN-RM Ruby E. Santiago RN-RM, MAN
09/11/2011 ; 7:45 pm J.N. ; 2361039 Normal Spontaneous Vaginal Delivery Rosalinda I. Morales, RN, MAN
08/28/2011 ; 5:02 pm A.G. ; 546040 Normal Spontaneous Vaginal Delivery Rosalinda I. Morales, RN, MAN
07/10/2011 ; 2:01 pm M.D. ; 536494 Normal Spontaneous Vaginal Delivery Ma. Blessel L. Abelardo RN
05/08/2011 ; 6:03 pm A.R. ; 506893 Normal Spontaneous Vaginal Delivery Anna Liza D. Lipana RN
Noted by: MRS. JOBBIE S. LACOPIA MS. MERLINA V. LOCQUIAO, RN, MAN, MAEd
(Print Name and Signature) (Print Name and Signature)139998 Valid Until: ### 123832 Valid Until:
Date document is signed: Time: Date document is signed: Time:Highest Nursing Degree Earned: Registerded Nurse, Certified Teacher, Master of Art's in Teaching Highest Nursing Degree Earned:
This part is applicable to all affiliate hospitals and maybe signed by the corresponding Chief Nurse/Head of the institution.
Noted by:
(Print Name and Signature)Valid Until:
Date document is signed: Time:Highest Nursing Degree Earned:
(STRICTLY NO DESIGNATES)Copies to: Dean; SRMD; PRC; Student (As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
Date Performed and Time Started
D.R. Nurse On Duty (Name and
Signature) (If Midwife on Duty, Signature
Not Required)
SUPERVISED BY Clinical Instructor Name and
Signature
Case Number (not applicable for
Birthing/ Lying-in Clinics/Homes)
Approved by:
Clinical Coordinator, PRC I.D. No.: Dean, PRC I.D. No.
Chief Nurse, PRC I.D. No.:
ODC Form 1AACTUAL DELIVERY FORM
AAF-NU 008
Rev. 1 3/7/2012 Page 1 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Web-Site: www.ceu.edu.ph
(STRICTLY NO DESIGNATES)(As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
ODC Form 1AACTUAL DELIVERY FORM
Page 1 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Address: No. 9 Mendiola St., San Miguel, ManilaTel. No.: 7356861 to 71 Loc. 219 Fax Number: 7362211
E-Mail Address:Web-Site: www.ceu.edu.ph
Accredited by: PAASCU Level II, May 13, 2011
SURGICAL SCRUB in Quezon City General Hospital, Dr. Jose Fabella Memorial Hospital, President Diosdado Macapagal Memorial Medical Center, East Avenue Medical Center Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: LOMEDA, RYAN ONEIL A.
Patient's INITIAL only
SURGICAL PROCEDURE PERFORMEDCase Number
2/7/2012 J.V. ; 015384 Open Cholecystectomy with Completion Cholangiogram Katherine Mapulla RN
11/3/2011 M.M. ; 429520 Low Transverse Cesarean Section Rose Karen Diaz RN-RM Veronica P. Cristobal RN-RM
5/14/2011 V.S. ; 149280 Exploratory Laparotomy Ileorrhaphy Aida T. Oliveros RN, MAN
4/6/2011 M.P. ; 37604 Low Transverse Cesarean Section Roberto P. Martires RN,MAN
4/5/2011 L.F. ; 37428 Exploratory Laparotomy Appendectomy Roberto P. Martires RN,MAN
Noted by: MRS. RAQUEL C. CRISTOBAL MS. MERLINA V. LOCQUIAO, RN, MAN, MAEd
(Print Name and Signature) (Print Name and Signature)276811 Valid Until: ### 123832 Valid Until:
Date document is signed: Time: Date document is signed: Time:Highest Nursing Degree Earned: Registered Nurse, Master of Arts in Nursing Highest Nursing Degree Earned:
This part is applicable to all affiliate hospitals and maybe signed by the corresponding Chief Nurse/Head of the institution.
Noted by:
(Print Name and Signature)Valid Until:
Date document is signed: Time:Highest Nursing Degree Earned:
(STRICTLY NO DESIGNATES)Copies to: Dean; SRMD; PRC; Student (As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
Date Performed and Time Started
O.R. Nurse On Duty (Name and
Signature) Not Required)
SUPERVISED BY Clinical Instructor Name and
Signature
Approved by:
Clinical Coordinator, PRC I.D. No.: Dean, PRC I.D. No.
Chief Nurse, PRC I.D. No.:
ODC Form 2AO.R. SCRUB FORM Major
AAF-NU 008
Rev. 1 3/7/2012 Page 2 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Web-Site: www.ceu.edu.ph
(STRICTLY NO DESIGNATES)(As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
ODC Form 2AO.R. SCRUB FORM Major
Page 2 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Address: No. 9 Mendiola St., San Miguel, ManilaTel. No.: 7356861 to 71 Loc. 219 Fax Number: 7362211
E-Mail Address:Web-Site: www.ceu.edu.ph
Accredited by: PAASCU Level II, May 13, 2011
ACTUAL DELIVERY in Dr. Jose Fabella Memorial Hospital, Pasig City General Hospital Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name and Signature of Student:
Patient's INITIAL only
09/15/11 ; 11:00 pm M.A. ; 421778 Normal Spontaneous Vaginal Delivery Milagros DJ. Canlas RN-RM Ruby E. Santiago, RN-RM, MAN
09/15/11 ; 12:10 am M.B. ; 405067 Normal Spontaneous Vaginal Delivery Milagros DJ. Canlas RN-RM Ruby E. Santiago, RN-RM, MAN
09/14/11 ; 11:55 pm R.O. ; 417015 Normal Spontaneous Vaginal Delivery Milagros DJ. Canlas RN-RM Ruby E. Santiago, RN-RM, MAN
07/09/11 ; 1:11 pm J.B. ; 541578 Normal Spontaneous Vaginal Delivery Ma. French Lyn C. Pascual RN
05/08/11 ; 10:28 am N. R. ; 574519 Normal Spontaneous Vaginal Delivery Anna Liza D. Lipana RN
Noted by: MRS. JOBBIE S. LACOPIA MS. MERLINA V. LOCQUIAO, RN, MAN, MAEd
(Print Name and Signature) (Print Name and Signature)139998 Valid Until: ### 123832 Valid Until:
Date document is signed: Time: Date document is signed: Time:Highest Nursing Degree Earned: Registerded Nurse, Certified Teacher, Master of Art's in Teaching Highest Nursing Degree Earned:
This part is applicable to all affiliate hospitals and maybe signed by the corresponding Chief Nurse/Head of the institution.
Noted by:
(Print Name and Signature)Valid Until:
Date document is signed: Time:Highest Nursing Degree Earned:
(STRICTLY NO DESIGNATES)Copies to: Dean; SRMD; PRC; Student (As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
Date Performed and Time Started
PROCEDURE PERFORMED Assisted Delivery
D.R. Nurse On Duty (Name and
Signature) (If Midwife on Duty, Signature
Not Required)
SUPERVISED BY Clinical Instructor Name and
Signature
Case Number (not applicable for
Birthing/ Lying-in Clinics/Homes)
Approved by:
Clinical Coordinator, PRC I.D. No.: Dean, PRC I.D. No.
Chief Nurse, PRC I.D. No.:
ODC Form 1BASSISTED DELIVERY
AAF-NU 008
Rev. 1 3/7/2012 Page 3 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Web-Site: www.ceu.edu.ph
(STRICTLY NO DESIGNATES)(As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
ODC Form 1BASSISTED DELIVERY
Page 3 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Address: No. 9 Mendiola St., San Miguel, ManilaTel. No.: 7356861 to 71 Loc. 219 Fax Number: 7362211
E-Mail Address:Web-Site: www.ceu.edu.ph
Accredited by: PAASCU Level II, May 13, 2011
SURGICAL SCRUB in Dr. Jose Fabella Memorial Hospital, Ospital ng Maynila, East Avenue Medical Center Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: LOMEDA, RYAN ONEIL A.
Patient's INITIAL only
SURGICAL PROCEDURE PERFORMED
2/6/2012 C.M. ; 439052 Post-partum with Sterilization with Bilateral Pomeroy Leticia M. Gollayan Teresa B. Talon RN-RM
2/6/2012 L.N. ; 420233 Post-partum with Sterilization with Bilateral Pomeroy Leticia M. Gollayan Teresa B. Talon RN-RM
10/16/2011 R. L. ; 2375277 Appendectomy Rosalinda I. Morales RN, MAN
9/14/2011 A.D. ; 414160 Dilatation and Curettage Socorro S. Arcinas RN-RM Ruby E. Santiago RN-RM, MAN
8/10/2011 J. N. ; 48665 Emergency Apendectomy Roberto P. Martires RN,MAN
Noted by: MRS. RAQUEL C. CRISTOBAL MS. MERLINA V. LOCQUIAO, RN, MAN, MAEd
(Print Name and Signature) (Print Name and Signature)276811 Valid Until: ### 123832 Valid Until:
Date document is signed: Time: Date document is signed: Time:Highest Nursing Degree Earned: Registered Nurse, Master of Arts in Nursing Highest Nursing Degree Earned:
This part is applicable to all affiliate hospitals and maybe signed by the corresponding Chief Nurse/Head of the institution.
Noted by:
(Print Name and Signature)Valid Until:
Date document is signed: Time:Highest Nursing Degree Earned:
(STRICTLY NO DESIGNATES)Copies to: Dean; SRMD; PRC; Student (As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
Date Performed and Time Started
O.R. Nurse On Duty (Name and
Signature)
SUPERVISED BY Clinical Instructor Name and
Signature
Case Number
Approved by:
Clinical Coordinator, PRC I.D. No.: Dean, PRC I.D. No.
Chief Nurse, PRC I.D. No.:
ODC Form 2BO.R. CIRCULATING FORM
AAF-NU 008
Rev. 1 3/7/2012 Page 4 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Web-Site: www.ceu.edu.ph
(STRICTLY NO DESIGNATES)(As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
ODC Form 2BO.R. CIRCULATING FORM
Page 4 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Address: No. 9 Mendiola St., San Miguel, ManilaTel. No.: 7356861 to 71 Loc. 219 Fax Number: 7362211
E-Mail Address:Web-Site: www.ceu.edu.ph
Accredited by: PAASCU Level II, May 13, 2011
IMMEDIATE NEWBORN CORD CARE in Pasig City General Hospital, Ospital ng Maynila Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by: Printed Name and Signature of Student:
Patient's INITIAL only
8/28/2011 ; 11:35 pm Bb. Boy S.A. Nursery Grenda M. Ugalde RN
8/26/2011 ; 8:30 pm Bb. Boy C. Nursery Rosalinda I. Morales, RN, MAN
8/19/2011 ; 9:02 pm Bb. Girl L.T. Nursery Rosalinda I. Morales, RN, MAN
7/9/2011 ; 11:42 am Bb. Boy L. Nursery Ma. French Lyn C. Pascual RN
5/08/2011 ; 7:12 am Bb. Girl M. Nursery Anna Liza D. Lipana RN
Noted by: MRS. JOBBIE S. LACOPIA MS. MERLINA V. LOCQUIAO, RN, MAN, MAEd
(Print Name and Signature) (Print Name and Signature)139998 Valid Until: ### 123832 Valid Until:
Date document is signed: Time: Date document is signed: Time:Highest Nursing Degree Earned: Registerded Nurse, Certified Teacher, Master of Art's in Teaching Highest Nursing Degree Earned:
This part is applicable to all affiliate hospitals and maybe signed by the corresponding Chief Nurse/Head of the institution.
Noted by:
(Print Name and Signature)Valid Until:
Date document is signed: Time:Highest Nursing Degree Earned:
(STRICTLY NO DESIGNATES)Copies to: Dean; SRMD; PRC; Student (As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
Date Performed and Time Started
IMMEDIATE NEWBORN CORD CARE PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
Nurse On Duty (Name and Signature)
(If Midwife on Duty, Signature
Not Required)
SUPERVISED BY Clinical Instructor Name and
Signature
Case Number (not applicable for
Birthing/ Lying-in Clinics/Homes)
Approved by:
Clinical Coordinator, PRC I.D. No.: Dean, PRC I.D. No.
Chief Nurse, PRC I.D. No.:
ODC Form 1CCORD CARE FORM
AAF-NU 008
Rev. 1 3/7/2012 Page 5 of 5
CENTRO ESCOLAR UNIVERSITYManila * Malolos * Makati
Web-Site: www.ceu.edu.ph
(STRICTLY NO DESIGNATES)(As per PRC BON Memorandum No. 02 s. 2009 dated June 15, 2009)
ODC Form 1CCORD CARE FORM
Page 5 of 5
