ODC Form 2B

O.R. MINOR
FORM
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph
Accredited by: AACCUP / Level II Re-accredited / February 2009
SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: CORTEZ, ANGELEEN ELIZABETH B.

Date Performed Patient’s INITIALS (only) SUPERVISED BY:

SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

March 06, 2010 A.B Wound Suturing under local Rebecca Ramchand R.N Ma. Divine Grace Marquez R.N
anesthesia
5:30 A.M 303020

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013 ___
Date document is signed: Time: Date document is signed: Time: ___
Please specify Highest Nursing Degree Earned: Master in Nursing _______ Specify Highest Nursing Degree Earned: Master in Nursing ___