University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: cn@post.upm.edu.ph ODC Form 1A
Website: http://cn.upm.edu.ph ACTUAL DELIVERY FORM

ACTUAL DELIVERY in Dr. Jose Fabella Memorial Hospital Manila, NCR

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student Cheska Mafaye R. Tablang

Patients INITIALS (only) O.R. Nurse On Duty

Date Performed (Name and Signature) SUPERVISED BY
Case Number
PROCEDURE
and (If Midwife on Duty, Clinical Instructor
Time Started (not applicable for Birthing/Lying- PERFORMED Signature Not Name and Signature
In Clinics/Homes) Required)
02-23-13 L.M. Actual Delivery Leilani F. Latras, RM, RN
9:45 am Case No. 497056 Normal Spontaneous Vaginal Delivery Lic No. 0062440/0235440
02-24-13 I.V. Actual Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
12:03 pm Case No. 497128 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-11-13 H.A. Actual Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
8:23 am Case No. 505451 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-11-13 J.A.A. Actual Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
10:21 am Case No. 507483 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-28-13 J.A. Actual Delivery Linda M. Villanueva, RM Leilani F. Latras, RM, RN
10:51 pm Case No. 510152 Normal Spontaneous Vaginal Delivery Lic No. 0033248 Lic No. 0062440/0235440

Noted by: ARNOLD B. PERALTA, BSN, MAN
(Print Name and Signature)
Clinical Coordinator, N-12
PRC ID NO. __________ Valid Until ____________
Date Signed: _________________ Time: ________
Noted by: IMELDA A. MAGASER, RN Approved by: ARACELI O. BALABAGNO, RN, PhD
(Print Name and Signature) (Print Name and Signature)
UP-PGH Deputy Director for Nursing Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________ PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________ Date Signed: ___________________ Time: ____________
(STRICTLY NO DESIGNATES)
 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: cn@post.upm.edu.ph ODC Form 1B
Website: http://cn.upm.edu.ph ASSISTED DELIVERY
FORM

ACTUAL DELIVERY in Dr. Jose Fabella Memorial Hospital Manila, NCR

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student Cheska Mafaye R. Tablang

Patients INITIALS (only) O.R. Nurse On Duty

Date Performed (Name and Signature) SUPERVISED BY
Case Number PROCEDURE
and (If Midwife on Duty, Clinical Instructor
Time Started (not applicable for Birthing/Lying- PERFORMED Signature Not Name and Signature
In Clinics/Homes) Required)
02-24-13 M.B. Assisted Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
7:14 am Case No. 463298 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-11-13 A.T.L. Assisted Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
7:35 am Case No. 507380 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-11-13 J.A. Assisted Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
9:04 am Case No. 507482 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-11-13 R.C. Assisted Delivery Janette M. Carlos RM Leilani F. Latras, RM, RN
11:50 am Case No. 497256 Normal Spontaneous Vaginal Delivery Lic No. 0098586 Lic No. 0062440/0235440
05-28-13 I.G. Assisted Delivery Linda M. Villanueva, RM Leilani F. Latras, RM, RN
11:25 pm Case No. 510171 Normal Spontaneous Vaginal Delivery Lic No. 0033248 Lic No. 0062440/0235440

Noted by: ARNOLD B. PERALTA, BSN, MAN
(Print Name and Signature)
Clinical Coordinator, N-12
PRC ID NO. __________ Valid Until ____________
Date Signed: _________________ Time: ________
Noted by: IMELDA A. MAGASER, RN
(Print Name and Signature)
UP-PGH Deputy Director for Nursing
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________
Approved by: ARACELI O. BALABAGNO, RN, PhD
(Print Name and Signature)
Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

(STRICTLY NO DESIGNATES)
 University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: cn@post.upm.edu.ph
Website: http://cn.upm.edu.ph ODC Form 1C
CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in Dr. Jose Fabella Memorial Hospital Manila, NCR
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student Cheska Mafaye R. Tablang

Patients INITIALS (only) Immediate Newborn Cord Care Nurse On Duty

Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(not applicable for Birthing Indicate where performed e.g. D.R., Nursery, (If Midwife on Duty,
Time Started Name and Signature
Homes/Lying-In Clinics/Homes) NICU, or Home signature not required)
Immediate Newborn Cord Care
05-29-13 F.D. Maribel Q. Bote RM, MAN Leilani F. Latras, RM, RN
PERFORMED
3:12 am Case No. 510186 Lic No. 0150551/0124960 Lic No. 0062440/0235440
Nursery
Immediate Newborn Cord Care
05-29-13 M.T. Maribel Q. Bote RM, MAN Leilani F. Latras, RM, RN
PERFORMED
4:10 am Case No. 495263 Lic No. 0150551/0124960 Lic No. 0062440/0235440
Nursery
Immediate Newborn Cord Care
06-02-13 E.M. Linda Villanueva, RM Leilani F. Latras, RM, RN
PERFORMED
6:11 am Case No. 509782 Lic No. 0033248 Lic No. 0062440/0235440
Nursery
Immediate Newborn Cord Care
06-02-13 A.M.V. Linda Villanueva, RM Leilani F. Latras, RM, RN
PERFORMED
8:17 am Case No. 510417 Lic No. 0033248 Lic No. 0062440/0235440
Nursery
Immediate Newborn Cord Care
06-02-13 R.R.T. Linda Villanueva, RM Leilani F. Latras, RM, RN
PERFORMED
10:06 am Case No. 510188 Lic No. 0033248 Lic No. 0062440/0235440
Nursery

Noted by: ARNOLD B. PERALTA, BSN, MAN
(Print Name and Signature)
Clinical Coordinator, N-12
PRC ID NO. __________ Valid Until ____________
Date Signed: _________________ Time: ________
Noted by: IMELDA A. MAGASER, RN Approved by: ARACELI O. BALABAGNO, RN, PhD
(Print Name and Signature) (Print Name and Signature)
UP-PGH Deputy Director for Nursing Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________ PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________ Date Signed: ___________________ Time: ____________
(STRICTLY NO DESIGNATES)