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Republic of the Philippines Mountain Province State Polytechnic College Bontoc, Mountain Province

ODC Form 2A
OR SCRUB FORM

SURGICAL SCRUB in BONTOC GENERAL HOSPITAL/ BONTOC MOUNTAIN PROVINCE /BAGUIO GENERAL HOSPITAL & MEDICAL CENTER/ BAGUIO CITY Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student DEPIA LEAH O. NGISLAWAN________________________

Date Performed and Time Started 12-08- 2012 3:44PM 02-28-2013 9:50am 03-01-2013 2:42pm.

Patients INITIALS (only) Case Number A.B 3445 L.Q. 678364 D. A. 679507

SURGICAL PROCEDURE PERFORMED Cholecystectomy TAHBSO IO PHC, ADHESIOLYSIS LND, Left SUPERFICIAL PAROTIDECTOMY with DISSECTION & PRESERVATION of CN VII

O.R. Nurse On Duty (Name and Signature) HEATHER HASMIN A. MOCYAT JAIME W. REYES STEVE C. CATACUTAN

SUPERVISED BY Clinical Instructor Name and Signature FLORITA A. SACGACA

ETHELBERT K. BANDAS

Noted by: _______________________________________________


Clinical Coordinator, (Print Name and Signature)
PRC I.D No. ________________ Valid Until ____________ ______ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________

Approved by: ___________________________________________________


(Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

Republic of the Philippines Mountain Province State Polytechnic College Bontoc, Mountain Province

ODC Form 2B
OR SCRUB FORM

SURGICAL SCRUB in

BAGUIO GENERAL HOSPITAL & MEDICAL CENTER/ BAGUIO CITY / Hospital, Municipality/City/Province

Prepared by: Printed Name with Signature of Student DEPIA LEAH O. NGISLAWAN____________________

Date Performed and Time Started 03- 02- 2013 1:00pm.

Patients INITIALS (only) Case Number K. P. C. 433379

SURGICAL PROCEDURE PERFORMED Emergency Low Segment Cesarean Section

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

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: _______________________________________________


(Print Name and Signature) Clinical Coordinator,
PRC I.D No. ________________ Valid Until ____________ ______ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________

Approved by: ___________________________________________________


(Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

Republic of the Philippines Mountain Province State Polytechnic College Bontoc, Mountain Province

ODC Form 1A
ACTUAL DELIVERY FORM

ACTUAL DELIVERY in BAGUIO GENERAL HOSPITAL & MEDICAL CENTER/ BAGUIO CITY/ BONTOC GENERAL HOSPITAL/ BONTOC MOUNTAIN PROVINCE Hospital, Home, Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student _DEPIA LEAH O. NGISLAWAN________________

Date Performed and Time Started 02- 19- 2013 10:49am 02-23- 2013 12:36am 03- 12- 2013 7:42am

Patients INITIALS (only) Case Number


(not applicable for Birthing/Lying-In Clinics/Homes)

PROCEDURE PERFORMED

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


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

M.C.F 681200 C. C. G. 378577 R.K 2973

Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

MICHELLE L. SUYAT DAISY M. GODDA IMELDA C. SAWI

ZUBAIDA P. ASTUDILLO ELENA A. TAL-UDAN FLORITA A. SACGACA

Noted by: _______________________________________________


(Print Name and Signature) Clinical Coordinator,
PRC I.D No. ________________ Valid Until ____________ ______ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________

Approved by: ___________________________________________________


(Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)

Republic of the Philippines Mountain Province State Polytechnic College Bontoc, Mountain Province
IMMEDIATE NEWBORN CORD CARE in

ODC Form 1B
IMMEDIATE NEWBORN CORD CARE FORM

LUIS HORA MEMORIAL REGIONAL HOSPITAL/ ABATAN BAUKO MOUNTAIN PROVINCE/ BAGUIO GENERAL HOSPITAL & MEDICAL CENTER/ BAGUIO CITY Hospital, Home, Lying-In Clinic Municipality/City/Province

Prepared by: Printed Name with Signature of Student __ DEPIA LEAH O. NGISLAWAN_____________________

Date Performed and Time Started 07- 16- 2012 05:58pm 02- 22- 2013 10:26pm. 02- 23- 2013 7:31pm

Patients INITIALS (only) Case Number


(not applicable for Birthing/Lying-In Clinics/Homes)

IMMEDIATE NEWBORN CORD CARE PERFORMED Indicate where performed e.g. D.R., NURSERY, NICU, or HOME NURSERY NURSERY NURSERY

Nurse On Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Bb. D. 056228 C.F.B 682009 C.B.D.L 681994

MARCELINA CAWALO KATRINA D. DOMINGO KATRINA D. DOMINGO

MARIBETH ANN T. BILLAO MAUREEN D. BARTOLOME MAUREEN D. BARTOLOME

Noted by: _______________________________________________

Approved by: ___________________________________________________

(Print Name and Signature) Clinical Coordinator,


PRC I.D No. ________________ Valid Until ____________ ______ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________

(Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________
Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________

(STRICTLY NO DESIGNATES)