PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)

General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph
SURGICAL SCRUB in
Prepared by:
Printed Name with Signature of
Student

Date Performed
and
Time Started

Patient's INITIALS (only)

November 25, 2013

9:45 AM

KJM
3984748

November 25, 2013

12:00 NN

LV
3855249

12:20 and
PM Signature)
(Print Name

SURGICAL PROCEDURE PERFORMED

Case Number
LD
3966448

Noted
by:November 25, 2013

UNIVERSITY OF THE PHILIPPINES PHILIPPINE GENERAL HOSPITAL

Hospital, Municipality/City/ Province

FABROS, DANIEL VINCENT E.

November 25, 20136:02 PM

November 25, 2013

9:53 PM

ODC Form 2A
O.R. SCRUB FORM
MAJOR

O.R Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Inferomedial Maxillectomy, Left

David Paul R. Ramos, RN, MAN

Open Reduction Internal Fixation Using Titanium Plates

And Screws With Intermandibulo-Maxillary
Fixation

David Paul R. Ramos, RN, MAN

Excission via Lateral Rhinotomy

David Paul R. Ramos, RN, MAN

CF
2654893

CTURP, Cystolithotomy

DR. GILMORE G. SOLIDUM

JOANEBC
M. OYANGOREN

David Paul R. Ramos, RN, MAN

Below Knee Amputation, Right

3463661

David Paul R. Ramos, RN, MAN

Clinical Coordinator,
Valid
December 12,
PRC I.D. No.
0422859
Until
2016
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree
Earned:
Master of Science in Nursing
Approve
d by:
(Print Name and Signature)

Dean, PRC
017202 Valid
I.D. No.
0
Until
Date document is
signed:
Please specify Highest Nursing
Degree Earned:

July 27, 2014

Tim
e
PhD

PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph
SURGICAL SCRUB in
Prepared by:
Printed Name with Signature of
Student

Date Performed
and
Time Started
January 6, 2014
5:30 PM
January 6, 2014
6:21 PM
January 6, 2014
8:20 PM
January 7, 2014
9:20 PM

Noted
by: January 7, 2014
6:00 PM

(Print Name and Signature)

ODC Form 2B
2A
MINOR FORM
O.R. SCRUB
FORM
MAJOR

JOSE REYES MEMORIAL MEDICAL CENTER

Hospital, Municipality/City/ Province

FABROS, DANIEL VINCENT E.

Patient's INITIALS (only)

SURGICAL PROCEDURE PERFORMED

O.R Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

JHG
919717

Wound Debridement and Suturing

Joan B. Yumul RN

Benjamin I. Tablizo Jr. RN, MAN

AA
919723

Wound Debridement and Suturing

Joan B. Yumul RN

Benjamin I. Tablizo Jr. RN, MAN

Left Foot, Incision and Drainage

Wound Exploration: Foreign Body Extraction and Suturing

Joan B. Yumul RN
Joan B. Yumul RN

Benjamin I. Tablizo Jr. RN, MAN

Case Number

CR
919666
MJD
920168

DR. GILMORE G. SOLIDUM

JOAN AIC
M. OYANGOREN
920038

Completion Aputation, Right Small Finger

Benjamin I. Tablizo Jr. RN, MAN

Joan B. Yumul RN
Benjamin I. Tablizo Jr. RN, MAN

Clinical Coordinator,
Valid
December 12,
PRC I.D. No.
0422859
Until
2016
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree
Earned:
Master of Science in Nursing
Approved
by:
(Print Name and Signature)

Dean, PRC I.D.

Valid
No.
0172020
Until
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree
Earned:
PhD

July 27,
2014

PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph
ACTUAL DELIVERY in

Prepared by:
Printed Name with Signature of
Student

Date Performed
and
Time Started

FABROS, DANIEL VINCENT E.

Gravida 4 Parity 2, 40 4/7 Weeks of Age of

Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery

IJTV
2627650

September 3, 2013
2:45 PM

Gravida 2 Parity 1, 38 Weeks of Age of Gestation,

Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery
Gravida 6 Parity 5, 39 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery

1606359
JSL

by:

PROCEDURE PERFORMED

Case Number
(not applicable for Birthing/Lying-In
Clinics/Homes)

RGP

September 9, 2013
7:10 PM
June
3, 2013
Noted
8:44 PM

OSPITAL NG MAYNILA MEDICAL CENTER, MANILA

Hospital, Municipality/City/ Province

Patient's INITIALS (only)

September 2, 2013
6:20 PM

1720623

DR. GILMORE G. SOLIDUM

KD

JOAN M.
OYANGOREN
2597085

(Print Name and Signature)

ODC
Form
ODC
Form
1A 2A
O.R.
SCRUB FORM
ACTUAL
DELIVERY
FORM
MAJOR

Gravida 1 Parity 0, 38 5/7 Weeks of Age of

Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery
Gravida 8 Parity 7, 41 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery

September
21, 2012
JSN
Clinical
Coordinator,
Valid
PRC I.D.6:16
No.PM
Until
1702010
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree Master of Arts in
Earned:
Nursing
Approved
by:

(Print Name and Signature)

Dean, PRC I.D.

Valid
No.
0172020
Until
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree
Earned:
PhD

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Christian Marie Apolo RN

Janet E. Lacsa, RN, RM, MAN

Tessa Jane H. Metran RN

Elaine Garcia RN

Janet E. Lacsa, RN, RM, MAN

Janet E. Lacsa, RN, RM, MAN

Tessa Jane H. Metran RN
Janet E. Lacsa, RN, RM, MAN
Maria Antonete Ramil RN
Janet E. Lacsa, RN, RM, MAN

PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph
ASSISTED DELIVERY in
Prepared by:
Printed Name with Signature of
Student

Date Performed
and
Time Started

OSPITAL NG MAYNILA MEDICAL CENTER, MANILA

Hospital, Municipality/City/ Province

FABROS, DANIEL VINCENT E.

Patient's INITIALS (only)

Case Number
(not applicable for
Birthing/Lying-In Clinics/Homes)
JAP

June 18, 2013

2:40 PM

2601465
SMAH

July 9, 2013
7:44 PM
July 15, 2013
7:22 PM
July 15, 2013
Noted
8:25 PM
by:

(Print Name and Signature)

ODC
Form
1B 2A
ODC
Form
ASSISTED
DELIVERY
O.R. SCRUB
FORM
FORM
MAJOR

2603805
MG
2609863
MBM

JOAN2609870
M. OYANGOREN

PROCEDURE PERFORMED
ASSISTED DELIVERY

Gravida 2 Parity 1, 39 Weeks of Age of

Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery
Gravida 1 Parity 0, 411/7 Weeks of Age of
Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery
Gravida 2 Parity 1, 38 5/7 Weeks of Age of
Gestation,
Pregnancy Uterine, Cephalic in Labor
NormalDR.
Spontaneous
Delivery
GILMORE
G. SOLIDUM
Gravida 3 Parity 2, 375/7 Weeks of Age of
Gestation,
Prenancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery
Gravida 4 Parity 3, 40 Weeks of Age of
Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Tessa Jane H. Metran RN

Janet E. Lacsa, RN, RM, MAN

Myra Dela Cruz RN

Myra Dela Cruz RN

Janet E. Lacsa, RN, RM, MAN

Janet E. Lacsa, RN, RM, MAN

Tessa Jane H. Metran RN

Clinical
Coordinator,
Valid
July 22,
2013
LR
PRC I.D.5:25
No.PM
Until
2613357
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree Master of Arts in
Earned:
Nursing
Approved
by:

(Print Name and Signature)

Dean, PRC I.D.

Valid
No.
0172020
Until
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree
Earned:
PhD

Janet E. Lacsa, RN, RM, MAN

Myra A. Ramil RN
Janet E. Lacsa, RN, RM, MAN

PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

ODC
Form
ODC
Form
1C 2A
O.R.CARE
SCRUB
FORM
CORD
FORM
MAJOR

IMMEDIATE NEWBORN CORD CARE in

Hospital, Municipality/City/ Province
Prepared by:
Printed Name with Signature of
Student

Date Performed
and
Time Started

Noted
by:

FABROS, DANIEL VINCENT E.

Patient's INITIALS (only)

IMMEDIATE NEWBORN CORD CARE

PERFORMED

Case Number
(not applicable for
Birthing/Lying-In Clinics/Homes)

Indicate where performed e.g. D.R., Nursery, NICU, or

Home

DR. GILMORE G. SOLIDUM

JOAN M. OYANGOREN

(Print Name and Signature)

Clinical Coordinator,
Valid
PRC I.D. No.
Until
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree Master of Arts In
Earned:
Nursing
Approved
by:
(Print Name and Signature)

Dean, PRC I.D.

Valid
No.
0172020
Until
Date document is
Tim
signed:
e
Please specify Highest Nursing Degree
Earned:
PhD

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
(Name and Signature)