Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City

063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
ACTUAL DELIVERY in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

Prepared by:
LAEH MAE A. ABUGAN

ODC Form 1A
ACTUAL DELIVERY
FORM

Patients INITIALS(only)
Date Performed
and
Time Started

June 10, 2015

01:54 am
June 14, 2015
12: 28 am
April 02, 2015
12:55 pm

Case Number
(not applicable for
Birthing/Lying-in
Clinics/Homes)
LG
090107
AM
238286
ER
231823

Noted by: VINCENT GO TABIL, RN MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0210024
Valid Until: April 15, 2017
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

PROCEDURE
PERFORMED

D.R Nurse On Duty

(Name and Signature)
(If midwife on duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

NSVD

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Elvie A. Paler
Lic. No.: 193311

NSVD

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561
ANNAMAE B. ADAMAT, MAN, RN
PRC 0714561

Gloria Shiela E. Coyoca

Lic. No.: 256493
Elvie A. Paler
Lic. No.: 193311

NSVD

Approved by: CLOWE D. JONDONERO, RN MAN

(Print Name and Signature)
Dean, PRC I.D No.0369698
Valid Until : September 12, 2015
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 1 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

ACTUAL DELIVERY in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

ODC Form 1B
ASSISTED

Prepared by:

DELIVERY FORM

LAEH MAE A. ABUGAN

Patients INITIALS(only)
Date Performed
and
Time Started

PROCEDURE
PERFORMED

D.R Nurse On Duty

(Name and Signature)
(If midwife on duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

NSVD

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Gloria Shiela E. Coyoca

Lic. No.: 256493

June 11, 2015

6:12 pm

Case Number
(not applicable for
Birthing/Lying-in
Clinics/Homes)
GC
238277

June 13, 2015

4:00 am

CS
238279

NSVD

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Elvie A. Paler
Lic. No.: 193311

June 10, 2015

5:30 am

DBA
237764

NSVD

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Elvie A. Paler
Lic. No.: 193311

Noted by: VINCENT GO TABIL, RN MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0210024

Valid Until: April 15, 2017

Approved by: CLOWE D. JONDONERO, RN MAN

(Print Name and Signature)
Dean, PRC I.D No.0369698
Valid Until : September 12, 2015

Date document is signed:__________________ Time:____________________

Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Date, document is signed:_______________

Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 1 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
IMMEDIATE NEWBORN CORD CARE in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte

ODC Form 1C
CORD CARE FORM

Prepared by
LAEH MAE A. ABUGAN

Patients INITIALS(only)
Date Performed
and
Time Started

Case Number
(not applicable for Birthing/Lyingin 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

April 15, 2015

5:30 pm

BB BOY M
232281

NICU

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Elvie A. Paler
Lic. No.: 193311

April 02, 2014

03:17 pm

BB GIRL A
221952

NICU

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Elvie A. Paler
Lic. No.: 193311

June 13, 2015

12: 44 am

BB BOY O
237809

NICU

ANNAMAE B. ADAMAT, MAN, RN

PRC 0714561

Elvie A. Paler
Lic. No.: 193311

Noted by: VINCENT GO TABIL, RN MAN

(Print Name and Signature)

Approved by: CLOWE D. JONDONERO, RN MAN

(Print Name and Signature)

Clinical Coordinator, PRC I.D No.0210024

Valid Until: April 15, 2017
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Dean, PRC I.D No.0369698

Valid Until : September 12, 2015
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 1 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

SURGICAL SCRUB in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
ODC Form 2A
O.R. SCRUB
FORM Major

Prepared by:
LAEH MAE A. ABUGAN

Patients INITIALS(only)
Date Performed
and
Time Started

SURGICAL PROCEDURE
PERFORMED

O.R Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Case Number

September 28, 2014

2:46 pm

CG
214853

Exploratory Laparotomy

BELEN JOY C. PATINDOL

PRC 0306764

Fesanmie D. Amarillo
Lic. No.: 363724

January 05, 2015

6:10pm

LT
223734

Appendectomy

BELEN JOY C. PATINDOL

PRC 0306764

Carmela Ortega
Lic No.: 390177

June 10, 2015

5:15 pm

RB
237087

Elective

BELEN JOY C. PATINDOL

PRC 0306764

Vincent G. Tabil
Lic. No.:210024

Noted by: VINCENT GO TABIL, RN MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0210024
Valid Until: April 15, 2017
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: CLOWE D. JONDONERO, RN MAN

(Print Name and Signature)
Dean, PRC I.D No.0369698
Valid Until : September 12, 2015
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Mindanao State University-Iligan Institute of Technology

Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 1 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)

SURGICAL SCRUB in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
ODC Form 2B
O.R. CIRCULATING
FORM

Prepared by:
LAEH MAE A. ABUGAN

Date Performed
and
Time Started

Patients
INITIALS(only)
Case Number

SURGICAL
PROCEDURE
PERFORMED

O.R Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

August 18, 2014

3:03 pm

DT
210105

Indirect Inguinal Hernia

Bilateral

BELEN JOY C. PATINDOL

PRC 0306764

Elvie A. Paler
Lic. No.: 193311

October 9, 2014
8:17 pm

FF
210225

ECCE with PCIOL Insertion

BELEN JOY C. PATINDOL

PRC 0306764

John Paul Ben T. Silang

Lic No.: 453695

June 10, 2015

02:25 pm

SS
237946

CS

BELEN JOY C. PATINDOL

PRC 0306764

Vincent G. Tabil
Lic. No.:210024

Noted by: VINCENT GO TABIL, RN MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D No.0210024
Valid Until: April 15, 2017
Date document is signed:__________________ Time:____________________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: CLOWE D. JONDONERO, RN MAN

(Print Name and Signature)
Dean, PRC I.D No.0369698
Valid Until : September 12, 2015
Date, document is signed:_______________
Time:_____________________
Specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING