UNIVERSITY OF PANGASINAN

COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrarupang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)
(Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976)







I. MA1OR OPERATIONS
No.
DATE of
OPERATION
TIME of
OPERATION
STARTED-
ENDED
PATIENT`S
INITIALS
DIAGNOSIS
OPERATION
PERFORMED
TYPE of
ANESTHESIA
NAME of
SURGEON
NAME of
HOSPITAL
Name & Signature of Qualified
Clinical Instructor
CASE NO.
1


January 17, 2011


11:15AM-
01:20PM


C.C.N


Inguinal Hernia
Right, Indirect
Incarcerated


Herniorraphy


Subarachnoid
Block


Dr. Nestor
Rivera



PMC




Stephanie E. De Vera, RN
723E
LEGEND:PMC Pangasinan Medical Center ( Tertiary )















Noted by: ZENAIDA M. BAUTISTA
Clinical Coordinator
PRC I.D. No.: 0133422 Valid Until: July 27, 2011
PNA No.: 040412 Valid Until: October 31, 2011
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.

Concurred by: VILMA D. PARAGAS
Chief Nurse
PRC I.D. No.: 020552 Valid Until: March 16, 2013
PNA No.: 040351 Valid Until: LiIetime Member
ANSAP No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: MAN in Progress

Approved by: MARIA TERESA R. FA1ARDO
Dean
PRC I.D. No.: 0160104 Valid Until: September 09, 2013
PNA No.: 040351 Valid Until: October 31, 2011
ADPCN No.: 19482 Valid Until: May 2011
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.

Supervised by: STEPHANE E. DE VERA
Clinical Instructor
Date signed:
Degree: BSN-RN
PRC I.D. No.: 0406035 Valid Until: May 06, 20011
PNA No.: 040411 Valid Until: October 31, 2011
NAME OF STUDENT: DELOS REYES, Elmer Dioquino

First course (iI any): Bachelor of Science in Physical Therapy
School graduated Irom: University of Pangasinan
Year: 1999
Year oI admission in the BSN Program: 2008
Year graduated Irom BSN Program: 2011
University Seal

Prepared by:

ELMER D. DELOSREYES
Student


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrarupang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)
(Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976)







II. MINOR OPERATIONS
No.
DATE of
OPERATION
TIME of
OPERATION
STARTED-
ENDED
PATIENT`S INITIALS
DIAGNOSIS
OPERATION
PERFORMED
TYPE of
ANESTHESIA
NAME of
SURGEON
NAME of
HOSPITAL
Name & Signature of
Qualified Clinical Instructor
CASE NO.
1


2


3


4


5


LEGEND:












NAME OF STUDENT:

First course (iI any):
School graduated Irom:
Year:
Year oI admission in the BSN Program:
Year graduated Irom BSN Program:
University Seal

Prepared by:


Student
Concurred by:
Chief Nurse
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:
ANSAP No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned:

Noted by: ZENAIDA M. BAUTISTA
Clinical Coordinator
PRC I.D. No.: 0133422 Valid Until: July 27, 2011
PNA No.: 013926 Valid Until: October 31, 2010
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.

Supervised by:
Clinical Instructor
Date signed:
Degree:
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:

Approved by: MARIA TERESA R. FA1ARDO
Dean
PRC I.D. No.: 0160104 Valid Until: September 09, 2013
PNA No.: 013739 Valid Until: October 31, 2010
ADPCN No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrarupang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)
(Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976)







III. ACTUAL DELIVERIES
No. DIAGNOSIS
MOTHER`S INITIALS
AGE
DATE of
DELIVERY
TIME of
DELIVERY
GENDER of
BABY
TYPE
of DELIVERY
NAME of
HOSPITAL
Name & Signature of
Qualified Clinical Instructor CASE NO.
1


2


3


4


5


LEGEND:














NAME OF STUDENT:

First course (iI any):
School graduated Irom:
Year:
Year oI admission in the BSN Program:
Year graduated Irom BSN Program:
University Seal

Prepared by:


Student
Concurred by:
Chief Nurse
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:
ANSAP No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned:

Noted by: ZENAIDA M. BAUTISTA
Clinical Coordinator
PRC I.D. No.: 0133422 Valid Until: July 27, 2011
PNA No.: 013926 Valid Until: October 31, 2010
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.

Supervised by:
Clinical Instructor
Date signed:
Degree:
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:

Approved by: MARIA TERESA R. FA1ARDO
Dean
PRC I.D. No.: 0160104 Valid Until: September 09, 2013
PNA No.: 013739 Valid Until: October 31, 2010
ADPCN No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrarupang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)
(Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976)







IV. ASSISTED DELIVERIES
No. DIAGNOSIS
MOTHER`S INITIALS
AGE
DATE of
DELIVERY
TIME of
DELIVERY
GENDER of
BABY
TYPE
of DELIVERY
NAME of
HOSPITAL
Name & Signature of
Qualified Clinical Instructor CASE NO.
1


2


3


4


5


LEGEND:














NAME OF STUDENT:

First course (iI any):
School graduated Irom:
Year:
Year oI admission in the BSN Program:
Year graduated Irom BSN Program:
University Seal

Prepared by:


Student
Concurred by:
Chief Nurse
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:
ANSAP No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned:

Noted by: ZENAIDA M. BAUTISTA
Clinical Coordinator
PRC I.D. No.: 0133422 Valid Until: July 27, 2011
PNA No.: 013926 Valid Until: October 31, 2010
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.

Supervised by:
Clinical Instructor
Date signed:
Degree:
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:

Approved by: MARIA TERESA R. FA1ARDO
Dean
PRC I.D. No.: 0160104 Valid Until: September 09, 2013
PNA No.: 013739 Valid Until: October 31, 2010
ADPCN No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.


UNIVERSITY OF PANGASINAN
COLLEGE OF NURSING
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrarupang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)
(Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976)







V. IMMEDIATE NEWBORN CORD CARE
No. DATE PERFORMED
TIME OF
DELIVERY
BABY`S INITIALS
GENDER of BABY MOTHER`S INITIALS AGE NAME of HOSPITAL
Name & Signature of
Qualified Clinical Instructor CASE NO.
1


2


3


4


5


LEGEND:














NAME OF STUDENT:

First course (iI any):
School graduated Irom:
Year:
Year oI admission in the BSN Program:
Year graduated Irom BSN Program:
University Seal

Prepared by:


Student
Concurred by:
Chief Nurse
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:
ANSAP No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned:

Noted by: ZENAIDA M. BAUTISTA
Clinical Coordinator
PRC I.D. No.: 0133422 Valid Until: July 27, 2011
PNA No.: 013926 Valid Until: October 31, 2010
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.

Supervised by:
Clinical Instructor
Date signed:
Degree:
PRC I.D. No.: Valid Until:
PNA No.: Valid Until:

Approved by: MARIA TERESA R. FA1ARDO
Dean
PRC I.D. No.: 0160104 Valid Until: September 09, 2013
PNA No.: 013739 Valid Until: October 31, 2010
ADPCN No.: Valid Until:
Date document is signed: Time:
Please SpeciIy Highest Nursing Degree Earned: M.A.N.