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PRC Cases Form

PRC Cases Form

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Published by: twothumbs on Jul 05, 2010
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URDANETA CITY UNIVERSITY 
(formerly City Colleges of Urdaneta)Urdaneta City, Philippines-2428 Tel No. (075) 568-2475
Adopted from BON Resolution No. 357Series of 2004
Name & Address of College of Nursing: ____________________________ Name of Student: _____________________________________________Last Course (if any): _________________________________________Status of Accreditation (if any): __________Date Granted: _________Year of Admission in the Bachelor of Science in Nursing Program: _____Date Nursing Program/College of Nursing was Recognized: June 17, 1985Year Graduated (BSN Program): ________________________________Recognition Number: 054Year: 1985
I. Major Operations
No.Date of OperationCaseNo.Name of PatientDiagnosisOperationPerformedType of AnesthesiaName of SurgeonName of HospitalName of QualifiedClinical Instructor Signature of QualifiedClinicalInstructor Name of O.R. ScrubNurseSignature of O.R. ScrubNurse1.2.3.4.5.Prepared by:Name of Student: _ Supervised by: ___________________________Concurred by:_______________________Concurred by:__ _____________________________ Name of Clinical InstructorChief NurseChief NurseDate Signed: _____________________________Date Signed: _______________________Date Signed: ________________________Degree: _________________________________Degree: ___________________________Degree: ____________________________a). PRC No.: _____________________________a). PRC No.: _______________________a). PRC No.: _______________________Valid Until: ____________________________ Valid Until: ______________________ Valid Until: _______________________b). PNA No.: _____________________________b). PNA No.: _______________________b). PNA No.: ________________________Valid Until: ____________________________ Valid Until: ______________________ Valid Until: _______________________c). ANSAP No. _____________________c). ANSAP No . ______________________Valid until: ______________________ Valid until: _______________________Noted by:
MS. JOSEPHINE R. BARNACHEA
Approved by:
MRS. ZOSIMA C. GARIN
Clinical Coordinator DeanDate Signed: ________________________________Date Signed: _________________________________ Degree: RN. BSN, MANDegree: RN, BSN Ma Ed. MANa). PRC No.: 0308841a). PRC No.: 0075349Valid Until: June 2010 Valid Until: Dec. 18, 2010b). PNA No.: 16531b). PNA No.: 12163Valid Until: Life Member Valid Until: Life member c). ADPCN No.:Valid Until: December 2008Name & Address of College of Nursing: ____________________________ 
 
URDANETA CITY UNIVERSITY 
(formerly City Colleges of Urdaneta)Urdaneta City, Philippines-2428 Tel No. (075) 568-2475
Adopted from BON Resolution No. 357Series of 2004
Name of Student: _____________________________________________Last Course (if any): _________________________________________Status of Accreditation (if any): __________Date Granted: _________Year of Admission in the Bachelor of Science in Nursing Program: _____Date Nursing Program/College of Nursing was Recognized: June 17, 1985Year Graduated (BSN Program): ________________________________Recognition Number: 054Year: 1985
II. Minor Operations
No.Date of OperationCaseNo.Name of PatientDiagnosisOperationPerformedType of AnesthesiaName of SurgeonName of HospitalName of QualifiedClinicalInstructor Signature of QualifiedClinicalInstructor Name of O.R. ScrubNurseSignature of O.R. ScrubNurse1.2.3.4.5.Prepared by:Name of Student: _ Supervised by: ___________________________Concurred by:_______________________Concurred by:__ _____________________________ Name of Clinical InstructorChief NurseChief NurseDate Signed: _____________________________Date Signed: _______________________Date Signed: ________________________Degree: _________________________________Degree: ___________________________Degree: ____________________________a). PRC No.: _____________________________a). PRC No.: _______________________a). PRC No.: _______________________Valid Until: ____________________________ Valid Until: ______________________ Valid Until: _______________________b). PNA No.: _____________________________b). PNA No.: _______________________b). PNA No.: ________________________Valid Until: ____________________________ Valid Until: ______________________ Valid Until: _______________________c). ANSAP No. _____________________c). ANSAP No . ______________________Valid until: ______________________ Valid until: _______________________Noted by:
MS. JOSEPHINE R. BARNACHEA
Approved by:
MRS. ZOSIMA C. GARIN
Clinical Coordinator DeanDate Signed: ________________________________Date Signed: _________________________________ Degree: RN. BSN, MANDegree: RN, BSN Ma Ed. MANa). PRC No.: 0308841a). PRC No.: 0075349Valid Until: June 2010 Valid Until: Dec. 18, 2010b). PNA No.: 16531b). PNA No.: 12163Valid Until: Life Member Valid Until: Life member c). ADPCN No.:Valid Until: December 2008Name & Address of College of Nursing: ____________________________ Name of Student: _____________________________________________Last Course (if any): _________________________________________
 
URDANETA CITY UNIVERSITY 
(formerly City Colleges of Urdaneta)Urdaneta City, Philippines-2428 Tel No. (075) 568-2475
Adopted from BON Resolution No. 357Series of 2004
Status of Accreditation (if any): __________Date Granted: _________Year of Admission in the Bachelor of Science in Nursing Program: _____Date Nursing Program/College of Nursing was Recognized: June 17, 1985Year Graduated (BSN Program): ________________________________Recognition Number: 054Year: 1985
III Actual Deliveries
No.CaseNo.DiagnosisName oPatientAgeDate ODeliveryTime of DeliveryGender Of BabyName of HospitalType Of Delivery
Supervised By:Name & Signatureof Qualified CI
1.2.3.4.5.
Prepared by:Name of Student: _ Concurred by:___________________________Concurred by:___________________________Concurred by:__________________________Chief NurseChief NurseChief NurseDate Signed: _____________________________Date Signed: _______________________Date Signed: ________________________Degree: _________________________________Degree: ___________________________Degree: ____________________________a). PRC No.: _____________________________a). PRC No.: _______________________a). PRC No.: _______________________Valid Until: ____________________________ Valid Until: ______________________ Valid Until: _______________________b). PNA No.: _____________________________b). PNA No.: _______________________b). PNA No.: ________________________Valid Until: ____________________________ Valid Until: ______________________ Valid Until: _______________________c). ANSAP No. ___________________________c). ANSAP No. _____________________c). ANSAP No . ______________________Valid until: ____________________________ Valid until: ______________________ Valid until: _______________________Noted by:
MS. JOSEPHINE R. BARNACHEA
Approved by:
MRS. ZOSIMA C. GARIN
Clinical Coordinator DeanDate Signed: ________________________________Date Signed: _________________________________ Degree: RN. BSN, MANDegree: RN, BSN Ma Ed. MANa). PRC No.: 0308841a). PRC No.: 0075349Valid Until: June 2010 Valid Until: Dec. 18, 2010b). PNA No.: 16531b). PNA No.: 12163Valid Until: Life Member Valid Until: Life member c). ADPCN No.:Valid Until: December 2008Name & Address of College of Nursing: ____________________________ Name of Student: _____________________________________________Last Course (if any): _________________________________________Status of Accreditation (if any): __________Date Granted: _________Year of Admission in the Bachelor of Science in Nursing Program: _____

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