Procedure Performed: Tarala, Gay Debonaire B

ODC Form 1
O.R. SCRUB
FORM
Minor
MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC.
1975 DONADA ST., PASAY CITY METRO MANILA 1300
TEL. NO. 525-91-91 LOC 282, FAX: (632) 5243256, email ad: mac_registrars office @yahoo.com
SURGICAL SCRUB in MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. NCR
Hospital, Municipality/City/Province
Prepared by:
Name of Student: TARALA, GAY DEBONAIRE B.
Student_____________________________
Signature of
Date Performed and

Time Started
Patients Initial/
Case Number
PROCEDURE
PERFORMED
February 13, 2012

10:20 am
Peralta J./ OP
Supra clavicular node

bx
Noted by:
O.R. Nurse on Duty

(Name and
Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
Many Jay T. Cancera

R.N.
Omer Rey T. Daquila
Concurred by:
Clinical Coordinator, (Print Name and Signature)___________________

Signature)__________________________
PRC I.D. No._____________________ Valid Until___________________
Until___________________
PNA No._______________________ Valid Until____________________
Until____________________
Date document is signed:___________________ Time:______________
Time:______________
Please specify Highest Nursing Degree Earned:_____________________
Earned:_____________________
Chief Nurse: Print Name and

PRC I.D. No._____________________ Valid
PNA No._______________________ Valid
Date document is signed:___________________
Please specify Highest Nursing Degree
ODC Form 1
O.R. SCRUB
FORM
Minor
Approved by: Dean, (Print Name and Signature)___________________
ADPCN No._____________________ Valid Until____________________
Prepared by:
Student_____________________________
Signature of
Date Performed and

Time Started
Patients Initial/
Case Number
PROCEDURE
PERFORMED
February 13, 2012

11:20 pm
Ruth Godezano/ OP
Mole Excision
Noted by:
O.R. Nurse on Duty

(Name and
Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
Marivi M. Pineda
Omer Rey T. Daquila
Concurred by:

Signature)__________________________
Until___________________
Until____________________

PRC I.D. No._____________________ Valid
PNA No._______________________ Valid
ODC Form 1
O.R. SCRUB
FORM
Time:______________
Earned:_____________________
Minor

Prepared by:
Student_____________________________
Signature of
Date Performed and

Time Started
Patients Initial/
Case Number
PROCEDURE
PERFORMED
O.R. Nurse on Duty

(Name and
Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
February 14, 2012

11:24 am
De Raya O./ OP
Breast Mass Excision Bx

(left)
James E. Ehurango
Omer T. Daquila
Noted by:
Concurred by:
ODC Form 1
O.R. SCRUB
FORM
Minor
Signature)__________________________
Until___________________
Until____________________
Time:______________
Earned:_____________________

PRC I.D. No._____________________ Valid
PNA No._______________________ Valid

Prepared by:
Student_____________________________
Date Performed and

Time Started
Patients Initial/
Case Number
Signature of
PROCEDURE
PERFORMED
O.R. Nurse on Duty

(Name and
Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
ODC Form 1
O.R. SCRUB
FORM
Minor
February 27, 2012
2:25 pm
Fernandez, Jose Nel/

1202-1691
Noted by:
Anal mass/
Hemoroidectomy
Marivi M. Pineda
Ricky G. Romulu
Concurred by:

Signature)__________________________
Until___________________
Until____________________
Time:______________
Earned:_____________________

PRC I.D. No._____________________ Valid
PNA No._______________________ Valid

Prepared by:
Student_____________________________
Signature of
ODC Form 1
O.R. SCRUB
FORM
Minor
Date Performed and

Time Started
Patients Initial/
Case Number
PROCEDURE
PERFORMED
O.R. Nurse on Duty

(Name and
Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
February 27, 2012

10:01 am
Angelyn Dungo
Doromal/ 1202-1673
Repair of the Floor

(right)
Marivi M. Pineda
Ricky G. Romulu
Noted by:
Concurred by:

Signature)__________________________
Until___________________
Until____________________
Time:______________
Earned:_____________________

PRC I.D. No._____________________ Valid
PNA No._______________________ Valid


Procedure Performed: Tarala, Gay Debonaire B

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Procedure Performed: Tarala, Gay Debonaire B

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ODC Form 1

Date Performed and

February 13, 2012

Supra clavicular node

O.R. Nurse on Duty

Many Jay T. Cancera

Omer Rey T. Daquila

Clinical Coordinator, (Print Name and Signature)___________________

Chief Nurse: Print Name and

Date Performed and

February 13, 2012

O.R. Nurse on Duty

Omer Rey T. Daquila

Clinical Coordinator, (Print Name and Signature)___________________

Chief Nurse: Print Name and

Approved by: Dean, (Print Name and Signature)___________________

Date Performed and

O.R. Nurse on Duty

February 14, 2012

Breast Mass Excision Bx

Chief Nurse: Print Name and

Approved by: Dean, (Print Name and Signature)___________________

Date Performed and

O.R. Nurse on Duty

Fernandez, Jose Nel/

Clinical Coordinator, (Print Name and Signature)___________________

Chief Nurse: Print Name and

Approved by: Dean, (Print Name and Signature)___________________

Date Performed and

O.R. Nurse on Duty

February 27, 2012

Repair of the Floor

Clinical Coordinator, (Print Name and Signature)___________________

Chief Nurse: Print Name and

Approved by: Dean, (Print Name and Signature)___________________

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