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CENTRAL PHILIPPINE ADVENTIST COLLEGE

SCHOOL OF NURSING P.O. Box 420, Bacolod City, Philippines 6100 Tel. No.: (034) 704-4530; Fax No.: (034) 704-4353 Email: nursing@cpac.edu.ph; Website: www.cpac.edu.ph ACSCU-AAI Accredited, Level II ACTUAL DELIVERY in BACOLOD ADVENTIST MEDICAL CENTER, Bacolod City, Negros Occidental ODC Form 1A ACTUAL DELIVERY FORM

Prepared by: Tañoso, Elah Viktoria N.
Date Performed and Time Started Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names) D.R. Nurse on Duty (Name and Signature) (if Midwife on duty, Signature Not Required) SUPERVISED BY Clinical Instructor (Name and Signature)

PROCEDURE PERFORMED

Noted by: Salvacion G. Ban, RN, MSN Clinical Coordinator, PRC I.D. No.: 0173883 Valid Until: March 29, 2013 Date document is signed: ________________________ Time: _____________ Highest Nursing Degree Earned: Master of Science in Nursing

Approved by: Joebenie L. De Villa, RN, MSN, PhD Dean, PRC I.D. No.: 0061260 Valid Until: April 17, 2014 Date document is signed: ________________Time:_______________ Highest Nursing Degree Earned: Doctor of Philosophy

Ban.ph. Date Performed and Time Started Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names) PROCEDURE PERFORMED ASSISTED DELIVERY D.: (034) 704-4353 Email: nursing@cpac. No.ph ACSCU-AAI Accredited. No.R. Bacolod City. Bacolod City. Nurse on Duty (Name and Signature) (if Midwife on duty. Fax No. De Villa. Website: www. MSN Clinical Coordinator. MSN. Box 420. Philippines 6100 Tel.: 0061260 Valid Until: April 17.CENTRAL PHILIPPINE ADVENTIST COLLEGE SCHOOL OF NURSING P. Level II ASSISTED DELIVERY in BACOLOD ADVENTIST MEDICAL CENTER. Signature Not Required) SUPERVISED BY Clinical Instructor (Name and Signature) Noted by: Salvacion G. No.edu.D.edu. PhD Dean.O.: 0173883 Valid Until: March 29. RN. PRC I. Elah Viktoria N. 2013 Date document is signed: ________________________ Time: _____________ Highest Nursing Degree Earned: Master of Science in Nursing Approved by: Joebenie L. 2014 Date document is signed: ________________Time:_______________ Highest Nursing Degree Earned: Doctor of Philosophy . RN.: (034) 704-4530. Negros Occidental ODC Form 1B ASSISTED DELIVERY FORM Prepared by: Tañoso. PRC I.cpac.D.

No. Bacolod City. Level II NEWBORN CARE in CORAZON BACOLOD ADVENTIST MEDICAL CENTER. Negros Occidental ODC Form 1C CORD CARE FORM Prepared by: Tañoso. De Villa. RN. Date Performed and Time Started Patient’s INITIALS (only) Case Number (not applicable for Birthing Home/Lying-in Clinics/Names) Immediate Newborn Cord Care PERFORMED (Indicate where performed e. NICU or Home) D.cpac.edu. Elah Viktoria N. Philippines 6100 Tel. RN. 2013 Date document is signed: ________________________ Time: _____________ Highest Nursing Degree Earned: Master of Science in Nursing Approved by: Joebenie L.: (034) 704-4353 Email: nursing@cpac.edu. DR. MSN Clinical Coordinator.: 0173883 Valid Until: March 29. PhD Dean. Bacolod City. Nurse on Duty (Name and Signature) (if Midwife on duty.CENTRAL PHILIPPINE ADVENTIST COLLEGE SCHOOL OF NURSING P. Signature Not Required) SUPERVISED BY Clinical Instructor (Name and Signature) Noted by: Salvacion G.O. Nursery.ph ACSCU-AAI Accredited. 2014 Date document is signed: ________________Time:_______________ Highest Nursing Degree Earned: Doctor of Philosophy . Fax No. PRC I. Ban. No.ph. PRC I. No. Box 420.R. Website: www.: 0061260 Valid Until: April 17.g.D. MSN.D.: (034) 704-4530.

Box 420. Philippines 6100 Tel. 2013 11:35 am Patient’s INITIALS (only) Case Number J. No.CENTRAL PHILIPPINE ADVENTIST COLLEGE SCHOOL OF NURSING P.O.R. Website: www. 2014 Date document is signed: ________________Time:_______________ Highest Nursing Degree Earned: Doctor of Philosophy . RN.R. Nurse on Duty (Name and Signature) SUPERVISED BY Clinical Instructor (Name and Signature) Elvie Ray Tapaya Lap Cholecystectomy Noted by: Salvacion G. De Villa. PRC I. SCRUB FORM MAJOR Prepared by: Tañoso.cpac. Bacolod City.: 0061260 Valid Until: April 17. No. Ban. S. PRC I.: (034) 704-4353 Email: nursing@cpac.edu.: 0173883 Valid Until: March 29.ph. Negros Occidental ODC Form 2A O.: (034) 704-4530. No. MSN Clinical Coordinator.ph ACSCU-AAI Accredited. RN. PhD Dean. Date Performed and Time Started February 4.D. M.edu. Level II SURGICAL SCRUB in BACOLOD ADVENTIST MEDICAL CENTER.D. Fax No. Bacolod City. 2013 Date document is signed: ________________________ Time: _____________ Highest Nursing Degree Earned: Master of Science in Nursing Approved by: Joebenie L. MSN. 1038188 SURGICAL PROCEDURE PERFORMED O. Elah Viktoria N.

No. 2013 Date document is signed: ________________________ Time: _____________ Highest Nursing Degree Earned: Master of Science in Nursing Approved by: Joebenie L.: (034) 704-4353 Email: nursing@cpac.R. Website: www.: (034) 704-4530.edu. Ban. PRC I. Level II CIRCULATING in BACOLOD ADVENTIST MEDICAL CENTER. Box 420. PRC I. Nurse on Duty (Name and Signature) SUPERVISED BY Clinical Instructor (Name and Signature) Noted by: Salvacion G. De Villa. Bacolod City. RN.: 0173883 Valid Until: March 29.R.O. No.ph. MSN.CENTRAL PHILIPPINE ADVENTIST COLLEGE SCHOOL OF NURSING P. No.: 0061260 Valid Until: April 17. Philippines 6100 Tel. Fax No.D. Negros Occidental ODC Form 2B O. MSN Clinical Coordinator. Bacolod City. CIRCULATING FORM Prepared by: Tañoso. PhD Dean.D. Date Performed and Time Started Patient’s INITIALS (only) Case Number SURGICAL PROCEDURE PERFORMED O.edu.cpac. RN. Elah Viktoria N. 2014 Date document is signed: ________________Time:_______________ Highest Nursing Degree Earned: Doctor of Philosophy .ph ACSCU-AAI Accredited.