OUR LADY OF FATIMA UNIVERSITY # 1 ESPERANZA ST.

HILLTOP HEIGHTS LAGRO, QUEZON CITY PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph PACUCOA LEVEL II, APRIL 10, 2002 SURGICAL SCRUB in OSPITAL NG SAMPALOC Hospital/Home/Municipality/City/Province

Prepared by: Printed Name and Signature of Student: SORIANO,KRISTINE JAN BERNADETTE G.
Patient's INITIAL 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

07/14/11(3:00pm) 07/22/11(3:35pm) 07/29/11(3:30pm)

C.R-969003 E.U-969103 E.C-639903

INCISION AND DRAINAGE PROCTOSIGMOIDOSCOPY EXCISION BIOPSY

Ms.SONIA LINAO,RN Ms.SONIA LINAO,RN Ms.SONIA LINAO,RN

Mr.ELBERT R.SALUT,RN,RM,MAN Mr.ELBERT R.SALUT,RN,RM,MAN Mr.ELBERT R.SALUT,RN,RM,MAN

Noted by: _____________________________________ MARISOL GARCIA MANIPOL RN, MAN Clinical Coordinator, PRC I.D. No. 0296870 Valid Until: SEPTEMBER 2012 PNA No: 013487 Valid Until: OCTOBER 31, 2010 Date document is signed: _______________ Time __________ Please specify Highest Nursing Degree Earned: BSN, MAN_

Approved by: _________________________________ NELIA R. CAPULONG RN, RM, MAN Dean, PRC I.D. No. 0041904 Valid Until: JULY 31, 2012 PNA No: 013487 Valid Until: OCTOBER 31, 2010 ADPCN No. 0627 Valid Until: December 2010 Date document is signed: _______________ Time _______ Please specify Highest Nursing Degree Earned: BSN, MAN

OUR LADY OF FATIMA UNIVERSITY # 1 ESPERANZA ST. HILLTOP HEIGHTS LAGRO, QUEZON CITY PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph PACUCOA LEVEL II, APRIL 10, 2002 SURGICAL SCRUB in OSPITAL NG SAMPALOC Hospital/Home/Municipality/City/Province

Prepared by: Printed Name and Signature of Student: SALIBIA,MARIBETH M.

Patient's INITIAL 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

07/21/11(2:17Pm) 07/22/11(3:10Pm) 07/28/11(2:35Pm)

P.G-643900 E.A-509503 E.S-009503

EXCISION BIOPSY DEBRIDEMENT EXCISION BIOPSY

Ms.SONIA LINAO,RN Ms.SONIA LINAO,RN Ms.SONIA LINAO,RN

Mr.ELBERT R.SALUT,RN,RM,MAN Mr.ELBERT R.SALUT,RN,RM,MAN Mr.ELBERT R.SALUT,RN,RM,MAN

Noted by: _____________________________________ MARISOL GARCIA MANIPOL RN, MAN Clinical Coordinator, PRC I.D. No. 0296870 Valid Until: SEPTEMBER 2012 PNA No: 013487 Valid Until: OCTOBER 31, 2010 Date document is signed: _______________ Time __________ Please specify Highest Nursing Degree Earned: BSN, MAN_

Approved by: _________________________________ NELIA R. CAPULONG RN, RM, MAN Dean, PRC I.D. No. 0041904 Valid Until: JULY 31, 2012 PNA No: 013487 Valid Until: OCTOBER 31, 2010 ADPCN No. 0627 Valid Until: December 2010 Date document is signed: _______________ Time _______ Please specify Highest Nursing Degree Earned: BSN, MAN