Sample- Or Dr Case 2013

BATAAN PENINSULA STATE UNIVERSITYCOLLEGE OF NURSING & MIDWIFERY

Don Manuel H. Banzon Avenue, Balanga City, Bataan

(047) 237-5477, [email protected]

Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )Level : 2Date of Accreditation: December 16, 2009

SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

Prepared by:

Name of Student : CECILLE INNA M. ANDAYA( Printed Name & Signature of Student )

Date Performed Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor

Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Name & Signature

Noted by: Concurred by: Approved by:

MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZ

Clinical Coordinator Chief Nurse Dean

PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477

Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Doctor of Philosophy Highest Degree Earned: Master of Arts in Nursing

O.R. Form 1-AMAJOR- O.R. CIRCULATING FORM -




Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. ( AACCUP )

Level : 2

Date of Accreditation: December 16, 2009


Prepared by:

Name of Student :( Printed Name & Signature of Student )




MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean

PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: Lifetime


Date document is signed: Date document is signed: Date document is signed:

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Prepared by:






PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374


Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:







Prepared by:






PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012


PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:






SURGICAL SCRUB in BATAAN GENERAL HOSPITAL, BALANGA, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

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MA. FLORINDA O. RUBIANO EVELYN R. RUBIA CAMILO D. DOMINGUEZ


Clinical Coordinator Chief Nurse DeanPRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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Name of Student : CATHERINE JOY R. BAUTISTA( Printed Name & Signature of Student )



01/03/12, 3:18pm N.C.R 175752 Emergency Low Cervical Cesarean Section Levie G. Roncal, RN Benjamin G. Kinney, MAN

01/04/12, 5:10pm L.A.R 175533 Total Mastectomy Right Maria Victoria T. Datu, RN Benjamin G. Kinney, MAN

01/11/12, 6:38pm J.M.C 176190 Emergency Exploratory Laparotomy; Appendectomy Levie G. Roncal, RN Benjamin G. Kinney, MAN




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O.R. Form 1-A MAJOR - O.R. SCRUB FORM






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PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: Lifetime



Time: Time: Time:







Prepared by:






PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374


Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:







Prepared by:






PRC I.D. No. : 0296587 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: November 4, 2013 Valid Until: October 22, 2014 Valid Until: July 18, 2012


PNA No. : 2012 - 024049 PNA No. : 7845 PNA No. : 14374Valid Until: December 2012 Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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IMMEDIATE NEWBORN CORD CARE in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

Prepared by:


Date Performed Patient's INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor

Time started ( not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, NICU, or Home ( if Midwife on Duty, Signature not required ) Name & Signature

11/16/12, 8:24 pm BB R. 176768 Delivery Room Leonora Fernandez, RMSylvia Pangilinan, MAN

11/17/12, 9:24 pm BB M. 176778Delivery Room

Leonora Fernandez, RMSylvia Pangilinan, MAN

11/23/12, 8:21 pm BB S. 176791Delivery Room

Grace Tamayo, RMSylvia Pangilinan, MAN


ROSITA D. VIANZON FERMINA Q. MERCADO CAMILO D. DOMINGUEZClinical Coordinator Senior Nurse Dean

PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:

Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: BSN, with MAN units Highest Degree Earned: Master of Arts in Nursing

ICNB FormIMMEDIATE CARE OF THE NEWBORN FORM





IMMEDIATE NEWBORN CORD CARE in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

Prepared by:





ROSITA D. VIANZON IMELDA P. DAVID CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean

PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:

Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Master Arts in Nursing Highest Degree Earned: Master of Arts in Nursing






IMMEDIATE NEWBORN CORD CARE in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

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PRC I.D. No. : 0086977 PRC I.D. No. : 0082691 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 8, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 11595 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: Lifetime



Time: Time: Time:







Prepared by:






PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374


Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:






IMMEDIATE NEWBORN CORD CARE in( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

Prepared by:





ROSITA D. VIANZON CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean

PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012


PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:

Highest Degree Earned: Master of Arts in Nursing Highest Degree Earned: Highest Degree Earned: Master of Arts in Nursing






Prepared by:






PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012


PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:







Prepared by:






PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477


Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:







Prepared by:







PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:







Prepared by:





ROSITA D. VIANZON CAMILO D. DOMINGUEZ


Clinical Coordinator Chief Nurse DeanPRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:







Prepared by:







PRC I.D. No. : 0086977 PRC I.D. No. : PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: Valid Until: July 18, 2012PNA No. : 13062 PNA No. : PNA No. : 14374Valid Until: Lifetime Valid Until: Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:






ACTUAL DELIVERY in ORANI DISTRICT HOSPITAL, ORANI, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

Prepared by:


Date Performed Patient's INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BYand Case Number PERFORMED ( Name & Signature ) Clinical Instructor

Time started ( not applicable for Birthing/Lying-In Clinics/Homes) ( if Midwife on Duty, Signature not required ) Name & Signature

11/16/12 3:55 pm A.M. 176773 Normal Spontaneous DeliveryLeonora Fernandez, RM Sylvia Pangilinan, MAN

13/01/12 9:39: pm C.S. 176813 Normal Spontaneous Delivery Leonora Fernandez, RM Sylvia Pangilinan, MAN

12/15/12 04:43 pm M.R. 176771 Normal Spontaneous Delivery Cecille Barion, RM Sylvia Pangilinan, MAN




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D. R. FormACTUAL DELIVERY

FORM





ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL, DINALUPIHAN, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

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ACTUAL DELIVERY in JOSE C. PAYUMO JR. MEMORIAL HOSPITAL( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

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PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: Lifetime


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PRC I.D. No. : 0086977 PRC I.D. No. : 062530 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: February 1, 2013 Valid Until: July 18, 2012


FORM

PNA No. : 13062 PNA No. : 4118 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

Time: Time: Time:






ACTUAL DELIVERY in BATAAN GENERAL HOSPITAL, BALANGA CITY, BATAAN( Hospital/ Home / Lying- In -Clinic, Municipality/ City/ Province )

Prepared by:





ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZClinical Coordinator Chief Nurse Dean

PRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012


FORM

PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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FORM

Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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ROSITA D. VIANZON EVELYN R. RUBIA CAMILO D. DOMINGUEZ


FORM

Clinical Coordinator Chief Nurse DeanPRC I.D. No. : 0086977 PRC I.D. No. : 98006 PRC I.D. No. : 0206477Valid Until: May 13, 2012 Valid Until: October 22, 2014 Valid Until: July 18, 2012PNA No. : 13062 PNA No. : 7845 PNA No. : 14374Valid Until: Lifetime Valid Until: Lifetime Valid Until: LifetimeDate document is signed: Date document is signed: Date document is signed:

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Documents

Sample- Or Dr Case 2013