Sample PRC Form of Me

OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: Bugarin,Aprilyn Poliquit____________________________________________________________________________

Name and Address of School: OUR LADY OF FATIMA UNIVERSITY #1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City_________
Accreditation Level (if any): PACUCOA Level II_______________________Year Granted: April 10, 2002________________________________
Date School/Program was Recognized: April 25, 2001________________Number: 033 ________________________Year: 2001____________
First Course (if any): NOT APPLICABLE_________________School Graduated From: NOT APPLICABLE_________Year: NOT APPLICABLE__
Year of Admission in the Bachelor of Science in Nursing Program: June 2006______________________________________________________
Year Graduated (BSN Program): March 2010_______________________________________________________________________________
I. Major Operations
No. Date of Case Name of Patient Diagnosis Operation Type of Name of Name of Supervised by Signature of
Operation No. Performed Anesthesia Surgeon Hospital Qualified CI Qualified CI
1. February 01659 Margareth judy Gravida2 Para2 Lower transverse spinal Dra. Imelda Balagtas Wilowena A.
16, 2009 cruz de guzman Cesarean section carreon Doctors Angeles
hospital RN,MAN
2. February 01662 Juaquin Cataract senile mature OD Cataract Monitored Dr. ronaldo Balagtas Wilowena A.
17, 2009 Zacarias Tan extraction OD Anesthesia Fernando Doctors Angeles
Care Hospital RN,MAN
3. February 01663 Salvacia Cataract senile mature OS Cataract Monitored Dr. ronaldo Balagtas Wilowena A.
17, 2009 Casquero vedra extraction OS Anesthesia Fernando Doctors Angeles
Care Hospital RN,MAN
4. October 09-11- Randy Magtibay Fractured Closed Complete Open Reduction Epidural Dr. San Jose Mrs. Liza
01, 2009 757 Comminuted Middle 3rd Femur Left Internal fixation Reynaldo District Vergara
middle 3rd femur Ozaeta Hospital
left
5. October 08-02- Airine Amitan Gravida2 Para0 Lower transverse Spinal Dra. Myla San Jose Mrs. Liza
05, 2009 283 Cesarean section Girao District Vergara
Hospital
Prepared by: Noted by: Concurred by: Approved by:
Bugarin,Aprilyn Poliquit Marisol Garcia –Manipol RN, MAN___ Lorna Punong Bayan Diano RN Nelia R. Capulong, RN, RM,MAN_
Signature over printed Name of Student Signature over printed name of Clinical Coordinator Signature over printed name of Signature over printed name of Dean
Date Signed: _______________ Chief Nurse Date Signed: _____________
Supervised by: Degree: RN, MAN____________ Date Signed: ___________ Degree: BSN, RM, MAN_____
_______________ a.) PRC NO: 0296870_________ Degree:_______________ a.) PRC NO: 0041904______
Signature over printed name of Faculty Valid Until: September, 2012 a.) PRC NO:0260345 Valid Until: July 31, 2012
Date Signed: ____________ b.) PNA NO: ________________ Valid Until: march 21 2013 b.) PNA NO: 18698_________
Degree: ________________ Valid Until: ____________ b.) PNA NO: ___________ Valid Until: Lifetime____
a.) PRC NO: __________ Valid Until: _________ c.) ADPCN NO: 0627_______
Valid Until: ________ Valid Until: ___________
b.) PNA NO: ___________
Valid Until:_________

II. Minor Operations

No. Date of Case No. Name of Patient Diagnosis Operation Type of Name of Surgeon Name of Hospital Supervised by Signature of
Operation Performed Anesthesia Qualified CI Qualified CI
1. May 11 Lacerated Wound
2009 186650 Garsula R-jay Right and left wound Suturing Local Dr. Ramon Teodoro Novaliches
palm District Hospital
2. May 12
2009 188377 Magpayo, Lipoma post trunk Excision General Dr. Jose Antonio Novaliches
Annabel Libunao District Hospital
3. October 01 Lacerated wound
2009 09-13-074 Pitugo, Kim right frontal area Suturing Local Dr.Milvin Ambal San jose district Mrs Liza
adrian hospital Vergara
4.
5.
Prepared by:
Noted by: Concurred by: Approved by:
Bugarin,Aprilyn Poliquit
Signature over printed Name of Student Marisol Garcia –Manipol RN, MAN___ Josephine B. Leonardo RN,PhD Nelia R. Capulong, RN, RM,MAN___
Signature over printed name of Clinical Coordinator Signature over printed name of Signature over printed name of Dean
Supervised by: Date Signed: _______________ Chief Nurse Date Signed: _____________
_______________ Degree: RN, MAN____________ Date Signed: ___________ Degree: BSN, RM, MAN_____
Signature over printed name of Faculty a.) PRC NO: 0296870_________ Degree:BSN,MAN a.) PRC NO: 0041904______
Date Signed: ____________ Valid Until: September, 2012 a.) PRC NO:0081174 Valid Until: July 31, 2012
Degree: ________________ b.) PNA NO: ________________ Valid Until: april 3 2011 b.) PNA NO: 18698_________
b.) PRC NO: __________ Valid Until: ____________ b.) PNA NO: 15614 Valid Until: Lifetime____
Valid Until: ________ Valid Until: Lifetime c.) ADPCN NO: 0627_______
b.) PNA NO: ___________ Valid Until: ___________

III. Actual Deliveries

No. Case Diagnosis Name of Mother Age Date of Time of Gender Name of Type of Delivery Supervised by:
No. Delivery Delivery of Baby Hospital Signature of Qualified
C.I.
1. 03- Pregnacy Uterine full Term Katherine B. Sorra 26 6:28am Male Philippine Normal spontaneous
12- Delivery Via Normal years October national police delivery
08 spontaneous Cephalic to old 01 2008 general hospial
alive Bb girl
2. 4011 Pregnancy uterine full term Jennele Reyes 33 April 15 8:30 pm Male Ospital ng san Normal spontaneous
09 gravida4 years 2009 jose del monte delivery
old
3. 4009 Pregnancy uterine full term Lea Amara 31 Decembe 10:00p Male Ospital ng san Normal spontaneous
63 gravida5para5 years r m jose del monte delivery
old 18 2009
4.
5.

Signature over printed Name of Student Marisol Garcia –Manipol RN, MAN___ Estelita B. Lorenzo,RN,RM,MAN Nelia R. Capulong, RN, RM,MAN___
Date Signed: ____________ Valid Until: September, 2012 b.) PRC NO: 0111348 Valid Until: July 31, 2012
Degree: ________________ b.) PNA NO: ________________ Valid Until: September 3 2011 b.) PNA NO: 18698_________
c.) PRC NO: __________ Valid Until: ____________ b.) PNA NO: ___________ Valid Until: Lifetime____
Valid Until: ________ Valid Until: _________ c.) ADPCN NO: 0627_______

IV. Deliveries Assisted

No. Case No. Diagnosis Name of Age Date of Time of Gender of Name of Hospital Type of Delivery
Mother Delivery Delivery Baby
1. 2111 Pregnancy uterine full term Helen 29 Septem 10:12 am Male Rural health center 3 Normal spontaneous
gravida 2 para 2 pancheto years ber 14 pulong buhangin, sta delivery
hubay old 2008 maria bulacan
2. 04-03-19 Pregnancy uterine full term Ma. 30 October 08:26pm Female Philippine national Normal spontaneous
gravida Theresa years 09 2008 police general hospital delivery
B. Sala old
3. 201046 Pregnancy uterine full term Lea 30 April 16 1:40pm Ospital ng san jose del Normal spontaneous
gravida3 Romero years 2008 Male monte delivery
old
4. 401079 Pregnancy uterine full term Rubilyn 28 April 18 11:45am Female Ospital ng san jose del Normal spontaneous
gravida2 Cutamero years 2008 monte delivery
old
5.
Prepared by:
Noted by: Concurred by: Approved by:
Signature over printed Name of Student Marisol Garcia –Manipol RN, MAN___ Estelita B. Lorenzo,RN,RM,MAN Nelia R. Capulong, RN, RM,MAN___
Date Signed: ____________ Valid Until: September, 2012 c.) PRC NO: 0111348 Valid Until: July 31, 2012
Degree: ________________ b.) PNA NO: ________________ Valid Until: September 3 2011 b.) PNA NO: 18698_________
d.) PRC NO: __________ Valid Until: ____________ b.) PNA NO: ___________ Valid Until: Lifetime____
Valid Until: ________ Valid Until: _________ c.) ADPCN NO: 0627_______

V. Cord Dressing
No. Case No. Date Name of Baby Gender of Name of Mother Age Name of Hospital Supervised by: Signature of
Performed Baby Qualified C.I.
1. 02-77-38 October 08 Baby girl of Tugbo,Eden Girl Eden Tugbo 35 years Philippine national police
2008 old general hospital
2. 401046 April 16 2009 Baby boy of Mabalatan, Boy Jocelle Mabalatan 21 years Ospital ng san jose del
Jocele old monte
3. 401069 April 17 2009 Baby boy of Pascau, Boy Soleta Pascua 25 years Ospital ng san jose del
Soleta old monte
4.
5.
Bugarin,Aprilyn Poliquit Marisol Garcia –Manipol RN, MAN___ Estelita B. Lorenzo,RN,RM,MAN Nelia R. Capulong, RN, RM,MAN___
Signature over printed Name of Student Signature over printed name of Clinical Coordinator Signature over printed name of Signature over printed name of Dean
Date Signed: _______________ Chief Nurse Date Signed: _____________
Supervised by: Degree: RN, MAN____________ Date Signed: ___________ Degree: BSN, RM, MAN_____
_______________ a.) PRC NO: 0296870_________ Degree:BSN,MAN a.) PRC NO: 0041904______
Signature over printed name of Faculty Valid Until: September, 2012 d.) PRC NO: 0111348 Valid Until: July 31, 2012
Date Signed: ____________ b.) PNA NO: ________________ Valid Until: September 3 2011 b.) PNA NO: 18698_________
Degree: ________________ Valid Until: ____________ b.) PNA NO: ___________ Valid Until: Lifetime____
a.) PRC NO: __________ Valid Until: _________ c.) ADPCN NO: 0627_______
Valid Until: ________ Valid Until: ___________
b.) PNA NO: ___________

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OUR LADY OF FATIMA UNIVERSITY

#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

Name of Student: Bugarin,Aprilyn Poliquit____________________________________________________________________________

Name of Student: Bugarin,Aprilyn Poliquit____________________________________________________________________________

II. Minor Operations

Name of Student: Bugarin,Aprilyn Poliquit____________________________________________________________________________

III. Actual Deliveries

Prepared by: Noted by: Concurred by: Approved by:

Name of Student: Bugarin,Aprilyn Poliquit____________________________________________________________________________

IV. Deliveries Assisted

Name of Student: Bugarin,Aprilyn Poliquit____________________________________________________________________________

Prepared by: Noted by: Concurred by: Approved by:

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