Mindanao Sanitarium & Hospital College

Barangay San Miguel, Iligan City 9200 Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshcnet@yahoo.com Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated Accreditation Level: Level II, April 29, 2011-April 2014 Accredited By: Adventist Accrediting Association Accreditation Level: Level II, October 4, 2010-December 31, 2012
ACTUAL DELIVERY in: Lanaodel Norte Provincial Hospital, Baroy, Lanaodel Norte_

D.R. Form ACTUAL DELIVERY FORM

Hospital/Home/Lying-in, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: ____HANIEYAH GRANDE GURO Date Performed and Time Started February11, 2010 10:45 AM Patients INITIAL Only Case Number (Not Applicable for Birthing/Lying-in Clinics/Homes) R.U. 05-41-09 D.R. Nurse on Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) Vilma M. Alvia, RN
PRC Number: 0069129 Valid Until: March 5, 2013

PROCEDURE PERFORMED

SUPERVISED BY: Clinical Instructor Name and Signature Lucy Mae L. Bucayan, MN, RN
PRC Number: 0193232 Valid Until: May 25, 2013

Handled Actual Delivery

Noted by:

MA. ALMIRA P. NEBRES, MAN, RN (Print Name and Signature) Clinical Coordinator, PRC I.D. No.: Valid Until: Date document is signed: Time: ______________________ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Approved by:

ROSELYN S. PACARDO, MAN, MM, RN, RM_____________ (Print Name and Signature) Dean, PRC I.D. No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Mindanao Sanitarium & Hospital College

Barangay San Miguel, Iligan City 9200 Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshcnet@yahoo.com Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated Accreditation Level: Level II, April 29, 2011-April 2014 Accredited By: Adventist Accrediting Association Accreditation Level: Level II, October 4, 2010-December 31, 2012
IMMEDIATE NEWBORN CORD CARE in:

ICNB Form IMMEDIATE CARE OF THE NEWBORN FORM

Hospital/Home/Lying-in, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: ____ Date Performed And Time Started Patients INITIAL Only Case Number (Not Applicable for Birthing/Lying-in Clinics/Homes) 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

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D. No.: Valid Until: Date document is signed: Time: ______________________ Please specify Highest Nursing Degree Earned:

Approved by: (Print Name and Signature) Dean, PRC I.D. No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned:

Mindanao Sanitarium & Hospital College

Barangay San Miguel, Iligan City 9200 Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshcnet@yahoo.com Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated Accreditation Level: Level II, April 29, 2011-April 2014 Accredited By: Adventist Accrediting Association Accreditation Level: Level II, October 4, 2010-December 31, 2012
SURGICAL SCRUB in:

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

Hospital/Home/Lying-in, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: ____ Date Performed and Time Started Patients INITIAL Only Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature) SUPERVISED BY: Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D. No.: Valid Until: Date document is signed: Time: ______________________ Please specify Highest Nursing Degree Earned:

Approved by: (Print Name and Signature) Dean, PRC I.D. No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned:

Mindanao Sanitarium & Hospital College

Barangay San Miguel, Iligan City 9200 Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshcnet@yahoo.com Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated Accreditation Level: Level II, April 29, 2011-April 2014 Accredited By: Adventist Accrediting Association Accreditation Level: Level II, October 4, 2010-December 31, 2012
CIRCULATING NURSE in:

O.R. Form 1B O.R. CIRCULATING FORM

Hospital/Home/Lying-in, Municipality/City/Province
Prepared by: Printed Name and Signature of Student: ____ Date Performed and Time Started Patients INITIAL Only Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature) SUPERVISED BY: Clinical Instructor Name and Signature

Noted by: (Print Name and Signature) Clinical Coordinator, PRC I.D. No.: Valid Until: Date document is signed: Time: ______________________ Please specify Highest Nursing Degree Earned:

Approved by: (Print Name and Signature) Dean, PRC I.D. No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned: