Republic of the Philippines ODC Form 1

UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM

COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER, BATAC, ILOCOS NORTE
Hospital, Municipality/City/Province
(MAJOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________
Supervised by
Date Performed and Patient’s Name O.R. Nurse On Duty
PROCEDURE PERFORMED Clinical Instructor
Time Started (Name only)
Case Number Name and Signature
DEBRIDEMENT SKELETAL
SEPTEMBER 06, 2010 ELMER ESPEJO TRACTION VALENTINA MENDOZA, RN JOEL PE BENITO BATIN, RM, RN
09:05 AM 100832
SEPTEMBER 07, 2010 MADELYN CAMALIG EMERGENCY LOW SEGMENT EVELYN GAJETON, RN JOEL PE BENITO BATIN, RM, RN
7:23 PM 593398 CAESAREAN SECTION
SEPTEMBER 14, 2010 RHOWENA TADLAS TOTAL ABDOMINAL OSCAR SADORRA, RN JOEL PE BENITO BATIN, RM, RN
5:03 PM 593106 HYSTERECTOMY WITH BILATERAL
SALPHINGO-OOPHORECTOMY

Noted by: VENERANDA L. QUICIO, RN Concurred by: MIRIAM R. RAMONES, RN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. ____________ Valid Until ____________________________
PNA No. __________ Valid Until _________________ PNA No. 5019 Valid Until ______LIFETIME___________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: __________________________________________

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
 Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Republic of the Philippines ODC Form 1

UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN ILOCOS TRAINING AND REGIONAL MEDICAL CENTER, SAN FERNANDO, LA UNION
Hospital, Municipality/City/Province
(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by Clinical
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty (Name
Instructor Name and
Time Started PERFORMED only)
Case Number Signature
APRIL 13, 2010 EVAN GAM-OS RAMOS FRACTIONAL CURETTAGE SALVADOR SOMERA, R.N. JOHN JASON ROL, RM, RN
9:22 PM 2010-0006572

Noted by: VENERANDA L. QUICIO, RN Concurred by: EMILIA ZENAIDA G. ROBLES, MAN
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _______________ Valid Until ________________________
PNA No. 015717 Valid Until LIFE MEMBER PNA No. 018915__ Valid Until ________LIFE MEMBER_______________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING MAJOR IN EDUCATION
 Republic of the Philippines ODC Form 1
UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN ABRA PROVINCIAL HOSPITAL, BANGUED, ABRA
Hospital, Municipality/City/Province
(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by Clinical
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty (Name
Instructor Name and
Time Started PERFORMED only)
Case Number Signature
NOVEMBER 29, 2010 RODRIGO BULDA APPLICATION OF ANTIMICROBIAL HAZELLE MENDOZA, R.N. HUSSEIN T. SIGANAY, RN, MAN
11:23 AM 919791 BEADS, CALCANEUS RIGHT

Noted by: VENERANDA L. QUICIO, RN Concurred by: KATHERINE F. CABUNOC, RN MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _____________ Valid Until _________________________
PNA No. __ Valid Until __________________________ PNA No. 9875 Valid Until ________LIFE MEMBER________________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 Republic of the Philippines ODC Form 1
UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN METRO VIGAN COOPERATIVE HOSPITAL, BANTAY, ILOCOS SUR
Hospital, Municipality/City/Province
(MAJOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by Clinical
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty (Name
Instructor Name and
Time Started PERFORMED only)
Case Number Signature
EXPLORATORY THORACOTOMY,
MARCH 25, 2011 MARK ALLEN VITE PERICARDIOTOMY AND JAROMY PSALM G. CARDENAS, AUGUST GREGOR LAZO, RM,RN
2:55 PM 11-0972 EVACUATION OF R.N.
HEMOPERICARDIUM

Noted by: VENERANDA L. QUICIO, RN Concurred by: JOSEFINA AGAM, MAN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012
PNA No. Valid Until _________________________
Date Document Is Signed:______________________ Time ________________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION
(Print Name and Signature)
Chief Nurse, PRC I.D. No. _____________ Valid Until __________________________
PNA No. 18228 Valid Until _____________LIFE MEMBER__________________
Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 Republic of the Philippines ODC Form 1
UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN SAINT JAMES HOSPITAL, VIGAN CITY, ILOCOS SUR
Hospital, Municipality/City/Province
(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by Clinical
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty (Name
Instructor Name and
Time Started PERFORMED only)
Case Number Signature
EXCISION OF BREAST MASS –
SEPTEMBER 03, 2009 TOMASA RACADIO RIGHT LOLITA QUINTUA, R.N GERARD GABRIEL REOTUTAR, RM, RN, MAN
2:09 PM 09-1937

Noted by: VENERANDA L. QUICIO, RN Concurred by: SR. ASSUNTA M. PRADO, OSB, MAN
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. ________________ Valid Until ______________________
PNA No. _______ Valid Until ___________________ PNA No. 15709 Valid Until __________LIFE MEMBER_____________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES ODC Form 1
COLLEGE OF HEALTH SCIENCES O.R. SCRUB FORM
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN GABRIELA SILANG GENERAL HOSPITAL, VIGAN CITY, ILOCOS SUR
Hospital, Municipality/City/Province
(MAJOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by Clinical
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty (Name
Instructor Name and
Time Started PERFORMED only)
Case Number Signature
APRIL 25, 2011 JENIFER PISCO OPEN REDUCTION INTERNAL ELVIE NAVARRO, RN HAZEL MAE RAGUNJAN, RN
12:15 PM 08030915 FIXATION – INTRAMEDULLARY
NAILING

Noted by: VENERANDA L. QUICIO, RN Concurred by: TERESITA F. AGATEP, MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _________________ Valid Until ____________________
PNA No. Valid Until _________________________ PNA No. __18229 Valid Until _________LIFE MEMBER_________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING MAJOR IN EDUCATION
 Republic of the Philippines ODC Form 1
UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN GABRIELA SILANG GENERAL HOSPITAL, VIGAN CITY, ILOCOS SUR
Hospital, Municipality/City/Province
(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by Clinical
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty (Name
Instructor Name and
Time Started PERFORMED only)
Case Number Signature
MARCH 25, 2011 EDGARDO ARELLANO HERNIORRHAPHY ELVIE NAVARRO, RN HAZEL MAE RAGUNJAN, RN
12:15 PM 08030936
APRIL O1, 2011 BERNADETH MANIEGO COMPLETION CURETTAGE ELVIE NAVARRO, RN HAZEL MAE RAGUNJAN, RN
10:03 AM 08028453
APRIL 01, 2011 ALMER PINTOR REMOVAL OF IMPLANT ELVIE NAVARRO, RN HAZEL MAE RAGUNJAN, RN
01:28 PM 08023844 RIGHT TIBIA

Noted by: VENERANDA L. QUICIO, RN Concurred by: TERESITA F. AGATEP, MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _________________ Valid Until ____________________
PNA No. Valid Until _________________________ PNA No. __18229 Valid Until _________LIFE MEMBER_________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR, RN (No Designates)

(Print Name and Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING