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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 Instructor’s 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 Instructor’s 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 Instructor’s full Name and signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI:
No erasures
Complete and correct data
Sign in blue pen

Pack Road.University of the Cordilleras COLLEGE OF NURSING Gov. 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 ) Instructor’s 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 Instructor’s full Name and signature PRC Number _______________ Validity ____________________ PNA Number _______________ Regular ( ) Life Time ( ) CI: No erasures . 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.