SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City (074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 FAX: (074) 442-2842 Website: www.slu.edu.ph ACCREDITED BY: PAASCU, LEVEL 2 Accreditation Status, 2005-2010

D.R. Form

ACTUAL DELIVERY In: _________________________________________________________ Hospital, Municipality/City/Province

ACTUAL DELIVERY FORM

Prepared by: _________________________________________ Printed Name with Signature

Date Performed And Time Started

Patients INITIALS Case Number

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City (074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 FAX: (074) 442-2842 Website: www.slu.edu.ph ACCREDITED BY: PAASCU, LEVEL 2 Accreditation Status, 2005-2010

D.R. Form

ASSIST DELIVERY in: ________________________________________________________

Hospital, Municipality/City/Province

ASSIST DELIVERY FORM

Prepared by: _________________________________________ Printed Name with Signature

Date Performed And Time Started

Patients INITIALS Case Number

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City (074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 FAX: (074) 442-2842 Website: www.slu.edu.ph ACCREDITED BY: PAASCU, LEVEL 2 Accreditation Status, 2005-2010

IMMEDIATE NEWBORN CORD CARE in: _______________________________________________ Hospital, Municipality/City/Province

ICNB Form IMMEDIATE CARE OF THE NEWBORN

Prepared by: _________________________________________ Printed Name with Signature

Date Performed And Time Started

Patients INITIALS Case Number

Immediate Newborn Cord Care WHERE PERFORMED

Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City (074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 FAX: (074) 442-2842 Website: www.slu.edu.ph ACCREDITED BY: PAASCU, LEVEL 2 Accreditation Status, 2005-2010

SURGICAL SCRUB in: ________________________________________________________

Hospital, Municipality/City/Province

O.R Form 1A O.R. SCRUB FORM Major

Prepared by: _________________________________________ Printed Name with Signature

Date Performed And Time Started

Patients INITIALS Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City (074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 FAX: (074) 442-2842 Website: www.slu.edu.ph ACCREDITED BY: PAASCU, LEVEL 2 Accreditation Status, 2005-2010

SURGICAL SCRUB in: ________________________________________________________

Hospital, Municipality/City/Province

O.R. Form 1C O.R. SCRUB FORM Minor

Prepared by: _________________________________________ Printed Name with Signature

Date Performed And Time Started

Patients INITIALS Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City (074) 442-3043; (074) 442-2793; (074) 442-8246 to 48 FAX: (074) 442-2842 Website: www.slu.edu.ph ACCREDITED BY: PAASCU, LEVEL 2 Accreditation Status, 2005-2010

SURGICAL SCRUB in: ________________________________________________________

Hospital, Municipality/City/Province

O.R Form 1B O.R. CIRCULATING FORM

Prepared by: _________________________________________ Printed Name with Signature

Date Performed And Time Started

Patients INITIALS Case Number

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature