LYCEUM-NORTHWESTERN UNIVERSITY

Tapuac District, Dagupan City

(075) 516-2429/ Fax No. (63) (75) 516-2434
Email: info@lyceum.edu.ph/www.lyceum.edu.ph
ACTUAL DELIVERY in PANGASINAN PROVINCIAL HOSPITAL, San Carlos City, Pangasinan
Hospital, Municipality/City/Province

Prepared by:
(Printed Name with Signature of Student)
Date Performed
and
Time Started

Patients INITIALS (only)

August 13, 2015

1:18 A.M.
August 26, 2015
2:48 A.M.
August 26, 2015
7:00 A.M.
August 26, 2015
11:35 P.M.
September 2, 2015
5:30 P.M.

L.dG.
#009188
R.C.
#012294
V.L.
#012442
R.dG.
#293598
J.M.B.
#014026

Case Number
(Not applicable for
Birthing/Lying-In
Clinics/Home)

Noted by: HILDA V. CRUZ

Clinical Coordinator
PRC I.D. No. __0321370
August 01, 2016

D.R. Form
ACTUAL DELIVERY
FORM

: MUMTA KHAMB

PROCEDURE PERFORMED

NORMAL SPONTANEOUS
DELIVERY
NORMAL SPONTANEOUS
DELIVERY
NORMAL SPONTANEOUS
DELIVERY
NORMAL SPONTANEOUS
DELIVERY
NORMAL SPONTANEOUS
DELIVERY

Valid Until: October 29, 2018

D.R. Nurse On Duty

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

Marie Joy V. Manuel,

RN
Jhona S. Austria, RN

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Czarina Anne D. Posadas, RN

MAN,PhD
Czarina Anne D. Posadas, RN
MAN,PhD
Jhona S. Austria, RN
Czarina Anne D. Posadas, RN
MAN,PhD
Jhona S. Austria, RN
Czarina Anne D. Posadas, RN
MAN,PhD
Jhona S. Austria, RN
Czarina Anne D. Posadas, RN
MAN,PhD
Approved by:
JUDITH M. MANUEL
College Dean
PRC I.D. No. 0104865_
Valid Until:

Date document is signed: ______________ Time: ______________________

____________________
Highest Nursing Degree Earned:
BSN, R.N., M.A.N.
M.A.N.

Date document is signed: _________

Time:

Highest Nursing Degree Earned:

BSN, R.N.,

LYCEUM-NORTHWESTERN UNIVERSITY
Tapuac District, Dagupan City
(075) 516-2429/ Fax No. (63) (75) 516-2434
Email: info@lyceum.edu.ph/www.lyceum.edu.ph
IMMEDIATE NEWBORN CORD CARE in PANGASINAN PROVINCIAL HOSPITAL, San Carlos City, Pangasinan
Hospital, Municipality/City/Province

Prepared by:
(Printed Name with Signature of Student)
Date
Performed
and
Time Started

January 14,
2015
8:40 A.M.
January 14,
2015
9:39 A.M.
January 15,
2015
7:46 A.M.
January 15,
2015
11:22 A.M.

Patients INITIALS (only)

: Kim Regino M.Calimlim

Indicate where performed e.g.

D.R.,Nursery, NICU, or Home

Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature not
Required)

B.B.A.
#219653

DELIVERY ROOM

Eden Orcullo, RN

B.B.R.
#219660

DELIVERY ROOM

Case Number
(Not applicable for
Birthing/Lying-In
Clinics/Home)

Immediate Newborn Cord Care

PERFORMED

ICNB Form
IMMEDIATE CARE OF
THE
NEWBORN FORM

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Czarina Anne D. Posadas, RN

MAN,PhD

Eden Orcullo,

Czarina Anne D. Posadas, RN

MAN,PhD

RN

B.B.L.
#225240

DELIVERY ROOM

Kristy Claveria, RN

B.G.L.
#225254

Czarina Anne D. Posadas, RN

MAN,PhD

DELIVERY ROOM

Kristy Claveria, RN

Czarina Anne D. Posadas, RN

MAN,PhD

Noted by: HILDA V. CRUZ

Approved by:

JUDITH M. MANUEL

Clinical Coordinator
PRC I.D. No. __0321370
Valid Until: October 29, 2018
August 01, 2016
Date document is signed: ______________ Time: ______________________
____________________
Highest Nursing Degree Earned:
BSN, R.N., M.A.N.
M.A.N.

College Dean
PRC I.D. No. 0104865_
Date document is signed: _________

Valid Until:
Time:

Highest Nursing Degree Earned:

BSN, R.N.,

LYCEUM-NORTHWESTERN UNIVERSITY
Tapuac District, Dagupan City
(075) 516-2429/ Fax No. (63) (75) 516-2434
Email: info@lyceum.edu.ph/www.lyceum.edu.ph
IMMEDIATE NEWBORN CORD CARE in BAYAMBANG DISTRICT HOSPITAL, Bayambang, Pangasinan
Hospital, Municipality/City/Province

Prepared by:
(Printed Name with Signature of Student) : MUMTA KHAMB
Date Performed
and
Time Started

September 10,
2015
7:23 A.M.

Patients INITIALS (only)

Case Number
(Not applicable for
Birthing/Lying-In
Clinics/Home)

B.G.A.
#148926

Noted by: HILDA V. CRUZ

Clinical Coordinator
PRC I.D. No. __0321370
August 01, 2016

Immediate Newborn Cord Care

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

Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature not Required)

DELIVERY ROOM

Abcde A. Fausto, RN

Valid Until: October 29, 2018

ICNB Form
IMMEDIATE CARE OF
THE
NEWBORN FORM

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Delia R. Escao, RN, MAN

Approved by:
JUDITH M. MANUEL
College Dean
PRC I.D. No. 0104865_

Valid Until:

Date document is signed: ______________ Time: ______________________

____________________
Highest Nursing Degree Earned:
BSN, R.N., M.A.N.
M.A.N.

Date document is signed: _________

Time:

Highest Nursing Degree Earned:

BSN, R.N.,