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University of the Cordilleras

COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
====================================
==========
SCRUB CASE SLIP: Major ( ) Minor ( ) Circulating ( )
Agency: _________________________________________________
Hospital ( )
Community ( ) Medical Mission (
)
Address: ________________________________________________
Name of Patient _________________________________________
Case Number ___________________ Age ______ Gender ______
Operation Performed _____________________________________
____________________________________________________
____________________________________________________
Date of Operation ________________________________________
Time started _____________ Time completed _______________
Scrub Nurse 1___________________________________________
Scrub Nurse 2___________________________________________
Circulating Nurse ________________________________________
Name of OR Nurse ________________________________________
_____________________________________________
Clinical Instructors full Name and signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI:
No erasures
Complete and correct data
Sign in blue pen

University of the Cordilleras


COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
====================================
==========
SCRUB CASE SLIP: Major ( ) Minor ( ) Circulating ( )
Agency: _________________________________________________
Hospital ( )
Community ( ) Medical Mission (
)
Address: ________________________________________________
Name of Patient _________________________________________
University of the Cordilleras
Case Number ___________________ Age ______ Gender ______
COLLEGE OF NURSING
Operation Performed _____________________________________
Gov. Pack Road, 2600 Baguio City
____________________________________________________
=====================================
____________________________________________________
=========
Date of Operation ________________________________________
DELIVERY CASE SLIP: Actual ( )
Assist ( )
Time started _____________ Time completed _______________
Scrub Nurse 1___________________________________________
Agency: ____________________________________________
Scrub Nurse 2___________________________________________
Hospital ( )
Home ( ) Birthing/
Circulating Nurse ________________________________________
Lying-in ( )
Name of OR Nurse ________________________________________
Address: ____________________________________________
Name of Mother ________________________________________
_____________________________________________
Case Number ___________________ Age ____________________
Clinical Instructors full Name and signature
Type of Delivery Attended _________________________________
PRC Number _______________ Validity ____________________
____________________________________________________
PNA Number _______________ Regular ( ) Life Time ( )
____________________________________________________
Date
of Delivery _________________________________________
CI:
Delivery
Started _____________ Delivery completed __________
No erasures
Actual
Nurse
___________________________________________
Complete and correct
data
Assist
___________________________________________
Sign
in Nurse
blue pen
Name of DR Nurse/ Midwife _______________________________
_________________________________
Clinical Instructors full Name and signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI:
No erasures
Complete and correct data
Sign in blue pen

University of the Cordilleras


COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
=====================================
=========
DELIVERY CASE SLIP: Actual ( )
Assist ( )
Agency: ____________________________________________
Hospital ( )
Home ( ) Birthing/
Lying-in ( )
Address: ____________________________________________
Name of Mother ________________________________________
Case Number ___________________ Age ____________________
Type of Delivery Attended _________________________________
____________________________________________________
University of the Cordilleras
____________________________________________________
COLLEGE OF NURSING
Date of Delivery _________________________________________
Gov.
Pack
Road, 2600
Baguio
City
Delivery Started _____________
Delivery
completed
__________
=====================================
Actual Nurse ___________________________________________
=========
Assist Nurse ___________________________________________
IMMEDIATE
NEWBORN
CARE CASE SLIP
Name of DR
Nurse/ Midwife
_______________________________
Agency: ____________________________________________
Hospital ( )
Home ( ) Birthing/
_________________________________
Lying-in ( Clinical
)
Instructors full Name and signature
Address: ____________________________________________
PRC Number _______________ Validity ____________________
Name
of Mother
________________________________________
PNA Number
_______________
Regular ( ) Life Time ( )
Name of Baby __________________________________________
Date of Delivery_________________ Time ___________________
CI:
No
erasures
Case
Number ___________________ Gender _________________
Complete
and
correct data
Immediate
Newborn
Care Performed at:
Sign in blue pen Delivery Room
(
)
Home
(
)
Nursery
(
)
Others _____________________________________
Name of Performing Nurse
___________________________________
Name of DR/ Nursery Nurse /Midwife:
_________________________
__________________________________________
Clinical Instructors full Name and signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI:
No erasures