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ODC Form 1

STI COLLEGE STA.CRUZ O.R. SCRUB FORM


Major
1522 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna

(049) 501-3446

SURGICAL SCRUB IN: BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas


Hospital/Municipality/City/Province

Prepared by:
Date Performed Patient’s Initial O.R. Nurse On SUPERVISED BY
and
Case Number
PROCEDURE Duty Clinical Instructor
Time Started Name and Signature
PERFORMED
Teodorico Laurel R.N., M.A.N.

Teodorico Laurel R.N., M.A.N.


Teodorico Laurel R.N., M.A.N.
Teodorico Laurel R.N., M.A.N.

Teodorico Laurel R.N., M.A.N.

Name of Student ______________________________________________ Signature of Student


___________________________________

BERNADETTE B. APOLO
Noted by: Concurred by: AMOR B.
CALAYAN
Clinical Coordinator Chief Nurse
PRC I.D No. 0084557 Valid Until: November 11, 2011 PRC I.D No. 151514 Valid Until: August 3, 2013
PNA No. 14922 Valid Until: Lifetime PNA No. 2011-048006 Valid Until: October 31, 2011
Date document is signed: _________________ Time ___________ Date document is signed: _______________ Time: ____________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: M.A.N, PhD

Approved by: FRANCISCA R. ARELLANO


Dean
PRC I.D No.0056168 Valid Until: March 2012
PNA No. 2011-032081 Valid Until October 31, 2011
Date document is signed: ________________ Time __________
Highest Nursing Degree Earned: M.A.N.

ODC Form 1
STI COLLEGE STA.CRUZ O.R. SCRUB FORM
Minor
1544 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna

(049) 808-3446

SURGICAL SCRUB IN: BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas


Hospital/Municipality/City/Province

Prepared by:

Name of Student ______________________________________________ Signature of Student ___________________________________

Date Performed Patient’s Initial O.R. Nurse On SUPERVISED BY


and
Case Number
PROCEDURE Duty Clinical Instructor
Time Started Name and Signature
PERFORMED
Teodorico Laurel R.N., M.A.N.

Teodorico Laurel R.N., M.A.N..

Teodorico Laurel R.N., M.A.N.


Teodorico Laurel R.N., M.A.N.

Teodorico Laurel R.N., M.A.N.

BERNADETTE B. APOLO
Noted by: Concurred by: AMOR B.
CALAYAN
Clinical Coordinator Chief Nurse
PRC I.D No. 0084557 Valid Until: November 11, 2011 PRC I.D No. 151514 Valid Until: August 3, 2013
PNA No. 14922 Valid Until: Lifetime PNA No. 2011-048006 Valid Until: October 31, 2011
Date document is signed: _________________ Time ___________ Date document is signed: _______________ Time: ____________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: M.A.N, PhD
Approved by: FRANCISCA R. ARELLANO
Dean
PRC I.D No.0056168 Valid Until: March 2012
PNA No. 2011-032081 Valid Until October 31, 2011
Date document is signed: ________________ Time __________
Highest Nursing Degree Earned: M.A.N.

ODC Form 2
STI COLLEGE STA.CRUZ ACTUAL DELIVERY
FORM
1544 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna

(049) 808-3446

ACTUAL DELIVERY in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Hospital/Home/Lying-In Clinic,
Municipality/City/Province

Prepared by:

Name of Student ___________________________________________ Signature of Student _______ _____________________________

Date Performed Patient’s Initial PROCEDURE D.R. Nurse on SUPERVISED BY


and PERFORMED Duty Clinical Instructor
Time Started Case Number Name and Signature
(not applicable for
Birthing/Lying-In
Clinics/Homes)

Gonzala B. De Mesa R.N., M.A.N


Gonzala B. De Mesa R.N., M.A.N
Gonzala B. De Mesa R.N., M.A.N
Gonzala B. De Mesa R.N., M.A.N

Gonzala B. De Mesa R.N., M.A.N


BERNADETTE B. APOLO
Noted by: Concurred by: AMOR B.
CALAYAN
Clinical Coordinator Chief Nurse
PRC I.D No. 0084557 Valid Until: November 11, 2011 PRC I.D No. 151514 Valid Until: August 3, 2013
PNA No. 14922 Valid Until: Lifetime PNA No. 2011-048006 Valid Until: October 31, 2011
Date document is signed: _________________ Time ___________ Date document is signed: _______________ Time: ____________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: M.A.N, PhD

Approved by: FRANCISCA R. ARELLANO


Dean
PRC I.D No.0056168 Valid Until: March 2012
PNA No. 2011-032081 Valid Until October 31, 2011
Date document is signed: ________________ Time __________
Highest Nursing Degree Earned: M.A.N.

STI COLLEGE STA.CRUZ ODC Form 3


D.R. ASSIST
FORM
1544 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna

(049) 808-3446

ASSISTED DELIVERY in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Hospital/Home/Lying-In Clinic,
Municipality/City/Province

Prepared by:

Name of Student _________________________________________ Signature of Student ___________________________________

Date Performed Patient’s Initial PROCEDURE D.R. Nurse On SUPERVISED BY


and Case Number PERFORMED Duty Clinical Instructor
Time Started (not applicable for Name and Signature
Birthing /Lying-In
Clinics/Homes)

Gonzala B. De Mesa R.N., M.A.N


Gonzala B. De Mesa R.N., M.A.N
Gonzala B. De Mesa R.N., M.A.N
Gonzala B. De Mesa R.N., M.A.N
Gonzala B. De Mesa R.N., M.A.N

BERNADETTE B. APOLO
Noted by: Concurred by: AMOR B.
CALAYAN
Clinical Coordinator Chief Nurse
PRC I.D No. 0084557 Valid Until: November 11, 2011 PRC I.D No. 151514 Valid Until: August 3, 2013
PNA No. 14922 Valid Until: Lifetime PNA No. 2011-048006 Valid Until: October 31, 2011
Date document is signed: _________________ Time ___________ Date document is signed: _______________ Time: ____________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: M.A.N, PhD

Approved by: FRANCISCA R. ARELLANO


Dean
PRC I.D No.0056168 Valid Until: March 2012
PNA No. 2011-032081 Valid Until October 31, 2011
Date document is signed: ________________ Time __________
Highest Nursing Degree Earned: M.A.N.

ODC Form 4
STI COLLEGE STA.CRUZ D.R. IMMEDIATE
NEWBORN
1544 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna CORD CARE FORM

(049) 808-3446

IMMEDIATE NEWBORN CORD CARE in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Hospital/Home/Lying-In Clinic,
Municipality/City/Province
Prepared by:

Name of Student ________________________________________ Signature of Student _________________________________________

Date Performed Patient’s Initial Immediate Newborn Cord Nurse On SUPERVISED BY


and Care PERFORMED Duty Clinical Instructor
Time Started Case Number Name and Signature
(not applicable for Indicate where performed e.g.
Birthing Homes/Lying-In D.R., Nursery, NICU, or Home
Clinics/Homes)

Bernadette B. Apolo R.N., M.A.N


Bernadette B. Apolo R.N., M.A.N

Bernadette B. Apolo R.N., M.A.N


Bernadette B. Apolo R.N., M.A.N

Bernadette B. Apolo R.N., M.A.N

BERNADETTE B. APOLO
Noted by: Concurred by: AMOR B.
CALAYAN
Clinical Coordinator Chief Nurse
PRC I.D No. 0084557 Valid Until: November 11, 2011 PRC I.D No. 151514 Valid Until: August 3, 2013
PNA No. 14922 Valid Until: Lifetime PNA No. 2011-048006 Valid Until: October 31, 2011
Date document is signed: _________________ Time ___________ Date document is signed: _______________ Time: ____________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: M.A.N, PhD

Approved by: FRANCISCA R. ARELLANO


Dean
PRC I.D No.0056168 Valid Until: March 2012
PNA No. 2011-032081 Valid Until October 31, 2011
Date document is signed: ________________ Time __________
Highest Nursing Degree Earned: M.A.N.