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PRC Case Form

PRC Case Form

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Published by iamELHIZA

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Published by: iamELHIZA on Jan 22, 2012
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01/22/2012

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MARTINEZ MEMORIAL COLLEGES198 A. Mabini St., Caloocan CityTelefax: 288-4279/ 287-5003
SURGICAL SCRUB in ___________________________________________________ Hospital, Municipality/ City/ ProvincePrepared by:Printed Name and Signature of Student _______________________________________________________ Date Performed and TimeStartedPatient’s INITIALSOnlyCase Number SURGICALPROCEDUREPERFORMEDO.R. Nurse on Duty(Name and Signature)SUPERVISED BY:Clinical Instructor  Name and Signature Noted by; __________________________________ 
(Print Name and Signature)Clinical Coordinator, PRC I.D. No. _______ Valid Until _________ Date document is signed ______________ Time _______________ Please specify Highest Degree Earned: _______________________ 
Approved by: __________________________________ 
(Print Name and Signature)Dean, PRC I.D. No. ___________________Valid Until ___________ Date document is signed ______________ Time _______________ Please specify Highest Degree Earned: _______________________ OR CIRCULATING FORM
 
MARTINEZ MEMORIAL COLLEGES198 A. Mabini St., Caloocan CityTelefax: 288-4279/ 287-5003
SURGICAL SCRUB in ___________________________________________________ Hospital, Municipality/ City/ ProvincePrepared by:Printed Name and Signature of Student _______________________________________________________ Date Performed and TimeStartedPatient’s INITIALSOnlyCase Number SURGICALPROCEDUREPERFORMEDO.R. Nurse on Duty(Name and Signature)SUPERVISED BY:Clinical Instructor  Name and Signature Noted by; __________________________________ 
(Print Name and Signature)Clinical Coordinator, PRC I.D. No. _______ Valid Until _________ Date document is signed ______________ Time _______________ Please specify Highest Degree Earned: _______________________ 
Approved by: __________________________________ 
(Print Name and Signature)Dean, PRC I.D. No. ___________________Valid Until ___________ Date document is signed ______________ Time _______________ Please specify Highest Degree Earned: _______________________ OR SCRUB FORMMajor 
 
MARTINEZ MEMORIAL COLLEGES198 A. Mabini St., Caloocan CityTelefax: 288-4279/ 287-5003
ACTUAL DELIVERY in ___________________________________________________ Hospital/ Home/ Lying-In Clinic, Municipality/ City/ ProvincePrepared by:Printed Name and Signature of Student _______________________________________________________ Date Performed and TimeStartedPatient’s INITIALSOnlyCase Number PROCEDUREPERFORMEDD.R. Nurse on Duty(Name and Signature)(if Midwife on Duty,Signature not Required)SUPERVISED BY:Clinical Instructor  Name and Signature Noted by; __________________________________ 
(Print Name and Signature)Clinical Coordinator, PRC I.D. No. _______ Valid Until _________ Date document is signed ______________ Time _______________ Please specify Highest Degree Earned: _______________________ 
Approved by: __________________________________ 
(Print Name and Signature)Dean, PRC I.D. No. ___________________Valid Until ___________ Date document is signed ______________ Time _______________ Please specify Highest Degree Earned: _______________________ Actual Delivery Form

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