University of The Visayas: Republic of The Philippines Professional Regulation Commission Board of Nursing

Republic of the Philippines Professional Regulation Commission Board of Nursing
ODC Form 2A
O.R. SCRUB FORM MAJOR
UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines TeleFax No. (032) 416-1538, 346-9292 loc. 622 Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013
SURGICAL SCRUB in Vicente Sotto Memorial Medical Center, B. Rodriguez St. Cebu City, Cebu Hospital/ Municipality/City/Province Prepared by: Printed Name and Signature of Student: Jayson T. Nadela Date Performed and Time Started
September 07, 2011 05:35 AM September 08, 2011 10:00 PM September 09, 2011 01:35 AM September 09, 2011 05:10 AM October 27, 2011 6:25 PM
Patients INITIAL only Case Number

A.S (276840) N.M (272170) I.A.C (272042) R.G (278162) M.G (84210)
SURGICAL PROCEDURE PERFORMED

Post-Partum Bilateral Tubal Ligation Below The Knee Amputation Debridement and Arthrotomy Appendectomy Appendectomy
O.R. Nurse on Duty (Name AND Signature)

Ms. Josephine Caputolan, RN Carmenia Sapio, RN Ginny Aguilar, RN Mrs. Florence Juntilla, RN Ms. Karissa Alcordo, RN
SUPERVISED BY Clinical Instructor Name and Signature

Ms. Joy M. Chiong, RN, MAN Ms. Joy M. Chiong, RN, MAN Ms. Joy M. Chiong, RN, MAN Ms. Joy M. Chiong, RN, MAN Ms. Maria Suzette M. Lanutan, RN
Noted by: MRS. YVONNE Y. PEAN Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Date Document Signed: ________________ Time: ____________________ Please specify Highest Degree Earned: RN, MAN_________________________
Approved by: MR. RESTY L. PICARDO______________________________ Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013____________ ADPCN No. : 20220 Valid Until: May 2011___________________ Date Document Signed: ________________ Time: _____________________ Please specify Highest Degree Earned: LLB, RN, MAN____________________
(STRICTLY NO DESIGNATES)
ODC Form 2B
O.R. CIRCULATING FORM

College of Nursing
SURGICAL SCRUB in Vicente Sotto Memorial Medical Center, B. Rodriguez St. Cebu City, Cebu Hospital/ Home/Lying-in clinical, Municipality/City/Province Prepared by: Printed Name and Signature of Student: Jayson T. Nadela Date Performed and Time Started
June 22,2011 02:45 PM September 7, 2011 03:40 AM October 19, 2011 - 10:20 AM October 27, 2011 11:00 AM October 27, 2011 11:48 AM
Patients INITIAL only Case Number

J.M.M (40348) A.C (272294) W.F (231367) R.G.L (813370) J.Y.M (283289)
SURGICAL PROCEDURE PERFORMED

Incision and Drainage Dressing Fine Needle Aspiration Biopsy Incision and Drainage with Drain Debridement & Suturing 5th Left Hand
O.R. Nurse on Duty (Name AND Signature)

Ms. Princess Mae V. Madarieta, RN Mr. Leandro Napoleon Lumapat, RN Mrs. Princess Mae Madarieta, RN Mrs. Preciosa V. Borinaga, RN Mrs. Preciosa V. Borinaga, RN

Mrs. Mercy Estillore, RN Mrs. Joy Chiong, RN Mrs. Lilibeth C. Dela Pena, RN MAN Mrs. Lilibeth C. Dela Pena, RN MAN Mrs. Lilibeth C. Dela Pena, RN MAN
Noted by: MRS. YVONNE Y. PEAN Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Date Document Signed: ________________ Time: _____________________ Please specify Highest Degree Earned: RN, MAN_________________________
Approved by: MR. RESTY L. PICARDO __ Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013 ADPCN No. : 20220 Valid Until: May 2011_______ Date Document Signed: ________ Time: ____________________ Please specify Highest Degree Earned: LLB, RN, MAN __
ODC Form 1A ACTUAL DELIVERY FORM

College of Nursing
ACTUAL DELIVERY in Tangke Barangay Health Center, Tangke, Talisay City Cebu Hospital/ Home/Lying-in clinical, Municipality/City/Province Prepared by: Printed Nam e and Signature of Student: Jayson T. Nadela Date Performed and Time Started Patients INITIAL only Case Number
(not applicable for Birthing Homes/Lying-in clinics/Homes)
PROCEDURE PERFORMED
O.R. Nurse on Duty (Name AND Signature) (If Midwife on duty, Signature not
required)

Mrs. Ezra May B. Condino, RN Mrs. Ezra May B. Condino, RN Mrs. Ezra May B. Condino, RN Mrs. Ezra May B. Condino, RN
June 21, 2011 12:30 AM June 23, 2011 05:35PM June 24, 2011 01:30 AM June 25, 2011 12:30 AM
J.O.P (65810) Y.C.C (41110) M.A.C (80420) C.M.N (34811)
Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery
Mrs. Brenda S. Pati, RN Mrs. Brenda S. Pati, RN Mrs. Brenda S. Pati, RN Mrs. Brenda S. Pati, RN
Approved by: MR. RESTY L. PICARDO _____ Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013____ ADPCN No. : 20220 Valid Until: May 2011___________ Date Document Signed: ________Time: _________________________ Please specify Highest Degree Earned: LLB, RN, MAN ______
ODC Form 1A ACTUAL DELIVERY FORM

College of Nursing
ACTUAL DELIVERY in Eversley Childs Sanitarium, Jagobiao, Mandaue City Cebu Hospital/ Home/Lying-in clinical, Municipality/City/Province Prepared by: Printed Nam e and Signature of Student: Jayson T. Nadela Date Performed and Time Started Patients INITIAL only Case Number
PROCEDURE PERFORMED
O.R. Nurse on Duty (Name AND Signature) (If Midwife on duty, Signature not
required)
SUPERVISED BY Clinical Instructor Name and Signature Ms Clare T. Reyes, RN
August 7, 2011 3:36 PM
A.T.L (11-33-93)
Normal Spontaneous Vaginal Delivery
Ms. Roella B. Ramirez, RN
Approved by: MR. RESTY L. PICARDO _____ Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013____ ADPCN No. : 20220 Valid Until: May 2011___________ Date Document Signed: ________ Time: ________________________ Please specify Highest Degree Earned: LLB, RN, MAN ____________
ODC Form 1B
ASSISTED DELIVERY FORM

College of Nursing
ACTUAL DELIVERY in Eversley Childs Sanitarium, Jagobiao, Mandaue City, Cebu Hospital/ Home/Lying-in clinical, Municipality/City/Province Prepared by: Printed Nam e and Signature of Student: Jayson T. Nadela Date Performed and Time Started Patients INITIAL only Case Number
PROCEDURE PERFORMED
ASSISTED DELIVERY
D.R. Nurse on Duty (Name AND Signature)

(If Midwife on duty, Signature not required)

Mrs. Clare T. Reyes, RN Ms. Charlotte B. Vicente, RN Mrs. Clare T. Reyes, RN Mrs. Clare T. Reyes, RN Ms. Mary Ann A. Aranas, RN
July 31, 2011 02:37 PM August 24, 2010 07: 36 PM September 3, 2011 04:09 PM September 3, 2011 5:45 PM September 8, 2010 03:54 PM
M.B (11-33-24) J.M.D (09-55-36) M.A (11-03-95) R.E (11-48-51) S.O.P (182140)
Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery Normal Spontaneous Vaginal Delivery
Ms. Roella B. Ramirez, RN Ms. Roella B. Ramirez, RN Ms. Jennifer P. Arcenal, RN Ms. Jennifer P. Arcenal, RN Ms. Narcia M. Calolot, RN
Approved by: MR. RESTY L. PICARDO _____ Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013____ ADPCN No. : 20220 Valid Until: May 2011___________ Date Document Signed: ________Time: _________________________ Please specify Highest Degree Earned: LLB, RN, MAN____________ (STRICTLY NO DESIGNATES)
ODC Form 1C CORD CARE FORM

College of Nursing
IMMEDIATE NEWBORN CORD CARE in Eversley Childs Sanitarium, Jagobiao, Mandaue City, Cebu Hospital/ Home/Lying-in clinical, Municipality/City/Province Prepared by: Printed Nam e and Signature of Student: Jayson T. Nadela Date Performed and Time Started Patients INITIAL only Case Number
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)

Mrs. Edna E. Reroma, RN, MAN Mrs. Clare T. Reyes, RN Mrs. Edna E. Reroma, RN, MAN Mrs. Charlotte Vicente, RN Mrs. Clare T. Reyes, RN
July 23, 2011 04:41 AM July 31, 2011 07:29 AM August 26, 2011 06:19 PM August 27, 2011 03:52 PM September 3, 2011 10:06 AM
M.M.T (101797) J.J.G (11-33-21) M.R.A (11-45-31) M.S.L ( 09-55-54) E.M (11-48-46)
Delivery Room Delivery Room Delivery Room Delivery Room Delivery Room
Ms. Lelibel J. Ochea, RN Ms. Roella B. Ramirez, RN Ms. Jennifer P. Arcenal, RN Ms. Jennifer P. Arcenal, RN Ms. Jennifer P. Arcenal, RN
Approved by: MR. RESTY L. PICARDO _____ Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013____ ADPCN No. : 20220 Valid Until: May 2011___________ Date Document Signed: ________Time: _________________________ Please specify Highest Degree Earned: LLB, RN, MAN____________

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