ODC Form 1

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
SURGICAL SCRUB in CAGAYAN VALLEY MEDICAL CENTER, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started April 17, 2012 7:25PM April 18, 2012 3:35PM April 18, 2012 5:00PM DASSUN, JOWEMA KRYSTEL A. Patients Name Case Number A.B 131920 J. L 133684 A.T 133706 O.R. Nurse On Duty (Name only)

O.R. SCRUB FORM Major

Signature of Student __________________________________ SUPERVISED BY Clinical Instructor Name and Signature

PROCEDURE PERFORMED Emergency repeat low segment cesarean section Open reduction internal fixation plating of radius ulna left Open reduction intramedullary nailing femur left

Debbie A. Taguba, RN, MSN Rei Marc Cipriano, RN Ace Monterubio, RN

AEGIE S. GARCIA RN, MSN, MAN AEGIE S. GARCIA RN, MSN, MAN AEGIE S. GARCIA RN, MSN, MAN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: OLIVIA S.B. GONZALES, RN, RM, MSN, MAN Chief Nurse, PRC I.D No. 0132834 Valid Until OCTOBER 3, 2015 PNA No. 16415 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING, MASTER OF ART IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

ODC Form 1

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
SURGICAL SCRUB in CAGAYAN VALLEY MEDICAL CENTER, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started April 16, 2012 3:35 PM April 23, 2012 6:35PM September 10, 2012 1:21PM DASSUN, JOWEMA KRYSTEL ADVIENTO Patients Name Case Number S.S 134342 S.M 134899 R.T 148422 O.R. Nurse On Duty (Name only)

O.R. SCRUB FORM Minor

Signature of Student ________________________________ SUPERVISED BY Clinical Instructor Name and Signature

PROCEDURE PERFORMED

Bilateral tubal ligation Completion Curettage Emergency debridement, chest thoracostomy tube insertion, left

Rei Marc Cipriano, RN

Cherubim Dumlao, RN, MSN

AEGIE S. GARCIA RN, MSN, MAN CHONA TAGUIBAO RN, MSN, MAN ROLANDO A. GAVINO III RN, MAN

Debbie Taguba, RN, MSN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: OLIVIA S.B. GONZALES, RN, RM, MSN, MAN Chief Nurse, PRC I.D No. 0132834 Valid Until OCTOBER 3, 2015 PNA No. 16415 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING, MASTER OF ART IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

ODC Form 2
ACTUAL DELIVERY FORM

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
ACTUAL DELIVERY in CAGAYAN VALLEY MEDICAL CENTER, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started DASSUN, JOWEMA KRYSTEL ADVIENTO Patients Name Case Number (not applicable for Birthing/Lying-In Clinics/Homes) R.A 135149 PROCEDURE PERFORMED D.R. Nurse/Midwife On Duty (Name only) Signature of Student __________________________________ SUPERVISED BY Clinical Instructor Name and Signature

April 24, 2012 6:46PM

Normal spontaneous delivery

Polyne Grace Acluba, RN

CHONA TAGUIBAO RN, MSN, MAN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: OLIVIA S.B. GONZALES, RN, RM, MSN, MAN Chief Nurse, PRC I.D No. 0132834 Valid Until OCTOBER 3, 2015 PNA No. 16415 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING, MASTER OF ART IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

ODC Form 2
ACTUAL DELIVERY FORM

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
ACTUAL DELIVERY in TUGUEGARAO CITY PEOPLES GENERAL HOSPITAL, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started DASSUN, JOWEMA KRYSTEL ADVIENTO Patients Name Case Number (not applicable for Birthing/Lying-In Clinics/Homes) A.D 12-5340 A.S 12-5343 PROCEDURE PERFORMED Signature of Student __________________________________ D.R. Nurse/Midwife On Duty (Name only) SUPERVISED BY Clinical Instructor Name and Signature

December 18,2012 10:15AM December 20,2012 7:00PM

Normal spontaneous delivery Normal spontaneous delivery

Domingo Caronan, RN Ma. Corazon Socorro L. Battung, RN, MSN

SUCENIA M. DE CENA RN, MSN SUCENIA M. DE CENA RN, MSN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: SUCENIA M. DE CENA RN, MSN Chief Nurse, PRC I.D No. 0125971 Valid Until JANUARY 18, 2015 PNA No. 17698 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

ODC Form 3
D.R. ASSIST FORM

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
ASSISTED DELIVERY in CAGAYAN VALLEY MEDICAL CENTER, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started DASSUN, JOWEMA KRYSTEL ADVIENTO Patients Name Case Number (not applicable for Birthing/Lying-In Clinics/Homes) S.M 134899 PROCEDURE PERFORMED D.R. Nurse/Midwife On Duty (Name only) Signature of Student __________________________________ SUPERVISED BY Clinical Instructor Name and Signature

April 23, 2012 6:35PM

Completion Curettage

Cherubim Dumlao, RN, MSN

CHONA TAGUIBAO RN, MSN, MAN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: OLIVIA S.B. GONZALES, RN, RM, MSN, MAN Chief Nurse, PRC I.D No. 0132834 Valid Until OCTOBER 3, 2015 PNA No. 16415 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING, MASTER OF ART IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

ODC Form 3
D.R. ASSIST FORM

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
ASSISTED DELIVERY in TUGUEGARAO CITY PEOPLES GENERAL HOSPITAL, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started DASSUN, JOWEMA KRYSTEL ADVIENTO Patients Name Case Number (not applicable for Birthing/Lying-In Clinics/Homes) K.D 12-5322 M.G 12-5349 PROCEDURE PERFORMED Signature of Student __________________________________ D.R. Nurse/Midwife On Duty (Name only) SUPERVISED BY Clinical Instructor Name and Signature

December 17,2012 7:11PM December 19,2012 10:41PM

Normal spontaneous delivery Normal spontaneous delivery

Ma. Corazon Socorro L. Battung, RN, MSN Ma. Corazon Socorro L. Battung, RN, MSN

SUCENIA M. DE CENA RN, MSN SUCENIA M. DE CENA RN, MSN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: SUCENIA M. DE CENA RN, MSN Chief Nurse, PRC I.D No. 0125971 Valid Until JANUARY 18, 2015 PNA No. 17698 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

ODC Form 4

UNIVERSITY OF CAGAYAN VALLEY College of Health College Avenue, Tuguegarao City 3500 Main Campus: Dr. Matias P. Perez Sr. Bldg. Phone Fax # (078) 844 8981
IMMEDIATE NEWBORN CORD CARE in CAGAYAN VALLEY MEDICAL CENTER, TUGUEGARAO CITY, CAGAYAN Hospital, Municipality/City/Province Prepared by: Name of Student: Date Performed and Time Started DASSUN, JOWEMA KRYSTEL ADVIENTO Patients Name Case Number (not applicable for Birthing Homes/Lying-In Clinics/Homes) Baby girl of K.F 130322 Baby girl of A.B 131920 Baby boy of E.C 83866 Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home

D.R. IMMEDIATE NEWBORN CORD CARE FORM

Signature of Student __________________________________ SUPERVISED BY Clinical Instructor Name and Signature

Nurse/Midwife On Duty (Name only)

February 24, 2012 3:55PM April 17, 2012 7:31PM September 11, 2012 11:41AM

Delivery Room Operating Room Operating Room

June Yvies Aquino, RN Debbie Taguba, RN, MSN Lilibeth Teao, RN

CHONA B. TAGUIBAO, RN, MSN, MAN AEGIE S. GARCIA RN, MSN, MAN ROLANDO A. GAVINO III RN, MAN

Noted by: CATHERINE MARIBBAY, RN, MSN Clinical Coordinator, PRC I.D No. 0170768 Valid Until SEPTEMBER 21, 2014 PNA No. ______________________ Valid Until ______________________________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING

Concurred by: OLIVIA S.B. GONZALES, RN, RM, MSN, MAN Chief Nurse, PRC I.D No. 0132834 Valid Until OCTOBER 3, 2015 PNA No. 16415 Valid Until LIFETIME Date document is signed: _________________________ Time: __________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING, MASTER OF ART IN NURSING

Approved by: ADRIANE GABRIELLE S. PEREZ, RN, RM, MSN (NO DESIGNATES) Dean, PRC I.D No. 0467837 Valid Until APRIL 14, 2014 PNA No. ______________________ Valid Until ______________________________ ADPCN No. 11 534 Valid Until MAY 31, 2013 Date document is signed: _________________________ Time ___________________ Please specify Highest Nursing Degree Earned: MASTER OF SCIENCE IN NURSING