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8/12/2019 Prc Form for the New Curriculum-march 2014
1/4
Southwestern University
College of NursingVilla Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email
Address: [email protected]
ACTUAL DELIVERY in
_______________________________________________________________________
Hospital / Home / Lying-In Clinic, Municipality / City /
Province
Prepared by:
Printed Name and Signature of Student
______________________________________
Date Performed and
Time Started
Patients INITIAL (only)
PROCEDURE
PERFORMED
D.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical InstructorName and Signature
Case Number
Noted by: ANTHONY JOSEPH C. MERCADO Approved by: BELINDA R.
ROSALES
OR/DR Clinical Coordinator, PRC I.D. No. 0401516 Valid Until
June 5, 2015 Dean, PRC I.D. No.0179732 Valid Until April 8,
2015Date document is signed:________Time____________ Date document
is signed:________Time________Please specify Highest Nursing Degree
Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MAN,
Ed.D.
D.R. FormACTUAL DELIVERY FO
mailto:[email protected]:[email protected]:[email protected]:[email protected]
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8/12/2019 Prc Form for the New Curriculum-march 2014
2/4
Southwestern University
College of NursingVilla Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email
Address: [email protected]
IMMEDIATE NEWBORN CORD CARE in
_______________________________________________________________________Hospital
/ Home / Lying-In Clinic, Municipality / City / Province
Prepared by:
Printed Name and Signature of Student
______________________________________
Date Performedand
Time Started
Patients INITIAL onlyImmediate Newborn Cord Care
PERFORMED
Indicate where performed e.g.
D.R. , Nursery, NICU, or Home
Nurse on Duty
(Name and Signature)
SUPERVISED BYClinical Instructor
Name and SignatureCase Number
Noted by: ANTHONY JOSEPH C. MERCADO Approved by: BELINDA R.
ROSALESOR/DR Clinical Coordinator, PRC I.D. No. 0401516 Valid Until
June 5, 2015 Dean, PRC I.D. No.0179732 Valid Until April 8,
2015Date document is signed:________Time____________ Date document
is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify
Highest Nursing Degree Earned: RN, MAN, Ed.D.
ICNB FormIMMEDIATE CARE OF THE
NEWBORN FORM
mailto:[email protected]:[email protected]:[email protected]:[email protected]
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8/12/2019 Prc Form for the New Curriculum-march 2014
3/4
Southwestern University
College of NursingVilla Aznar Urgello Street Cebu City
Phone no: 415-55-55 local 183, Telefax: 418-72-78, Email
Address: [email protected]
SURGICAL SCRUB in
_______________________________________________________________________
Hospital, Municipality / City / Province
Prepared by:
Printed Name and Signature of Student
______________________________________
Date Performed
and
Time Started
Patients INITIAL only SURGICAL PROCEDUREPERFORMED
O.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and SignatureCase Number
Noted by: ANTHONY JOSEPH C. MERCADO Approved by: BELINDA R.
ROSALES
OR/DR Clinical Coordinator, PRC I.D. No. 0401516 Valid Until
June 5, 2015 Dean, PRC I.D. No.0179732 Valid Until April 8,
2015Date document is signed:________Time____________ Date document
is signed:________Time________Please specify Highest Nursing Degree
Earned: RN, MAN Specify Highest Nursing Degree Earned: RN, MAN,
Ed.D.
O.R. Form 1AO.R. SCRUB FORM
Major
mailto:[email protected]:[email protected]:[email protected]:[email protected]
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8/12/2019 Prc Form for the New Curriculum-march 2014
4/4
Southwestern UniversityCollege of Nursing
Villa Aznar Urgello Street Cebu CityPhone no: 415-55-55 local
183, Telefax: 418-72-78, Email Address: [email protected]
MAJOR CIRCULATOR in
_______________________________________________________________________
Hospital, Municipality / City / Province
Prepared by:Printed Name and Signature of Student
______________________________________
Date Performed
andTime Started
Patients INITIAL onlySURGICAL PROCEDURE
PERFORMEDO.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical InstructorName and Signature
Case Number
Noted by: ANTHONY JOSEPH C. MERCADO Approved by: BELINDA R.
ROSALESOR/DR Clinical Coordinator, PRC I.D. No. 0401516 Valid Until
June 5, 2015 Dean, PRC I.D. No.0179732 Valid Until April 8,
2015Date document is signed:________Time____________ Date document
is signed:________Time________
Please specify Highest Nursing Degree Earned: RN, MAN Specify
Highest Nursing Degree Earned: RN, MAN, Ed.D.
O.R. Form 1BO.R. CIRCULATING
FORM
mailto:[email protected]:[email protected]:[email protected]:[email protected]
