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Midwifery Delivery Record Template

This document is a record of deliveries handled and procedures performed by a midwife from their school. It includes tables to log the name and address of patients, date, location of delivery or procedure, hospital case number if applicable, and supervising medical professional for deliveries and procedures like suturing and intravenous insertions. Spaces are provided to log details of up to 20 deliveries and 5 each of suturing and intravenous insertion procedures. The record must be certified by the chief of hospital and notarized.

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azzkickah
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91 views4 pages

Midwifery Delivery Record Template

This document is a record of deliveries handled and procedures performed by a midwife from their school. It includes tables to log the name and address of patients, date, location of delivery or procedure, hospital case number if applicable, and supervising medical professional for deliveries and procedures like suturing and intravenous insertions. Spaces are provided to log details of up to 20 deliveries and 5 each of suturing and intravenous insertion procedures. The record must be certified by the chief of hospital and notarized.

Uploaded by

azzkickah
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd

PROFESSIONAL REGULATION COMMISSION

Manila

BOARD OF MIDWIFERY
RECORD OF DELIVERIES HANDLED

NAME: SCHOOL:

Supervised by
Name of Patient Address Date Name of Hospital Hospital Case Number Check if Home Delivery Name in Print Signature Designation Registration Number
1
2
3
4
5
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9
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20
SUTURING
Supervised by
Name of Patient Address Date Name of Hospital Hospital Case Number Check if Home Delivery Name in Print Signature Designation Registration Number
1
2
3
4
5

INTRAVENOUS INSERTIONS
Supervised by
Name of Patient Address Date Name of Hospital Hospital Case Number Check if Home Delivery Name in Print Signature Designation Registration Number
1
2
3
4
5

CERTIFIED CORRECT:

CHIEF OF HOSPITAL

SUBSCRIBED AND SWORN to before me this _____________ day of ___________ at _________________, Philippines. Affiant exhibited to me his/her Community Tax Certificate Number ____________
issued on _____________________________________ at ________________________.

________________________________________________________________________________
Notary Public

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