You are on page 1of 1

Mindanao Sanitarium & Hospital College

School of Nursing
Barangay San Miguel, Iligan City 9200
Phone No.(063) 221-9219, Fax No. (063) 223-2114, mshnet@yahoo.com
Accredited By: Association of Christian Schools, Colleges and Universities Accrediting Agency, Incorporated
Accreditation Level: Level II, April 29, 2011 April 2014
Accredited By: Adventist Accrediting Association
Accreditation Level: Level II, October 4, 2010-December 31, 2012

SURGICAL SCRUB in: Gregorio T. Lluch Memorial Hospital, Palao, Iligan City
Adventist Medical Center, Barangay San Miguel, Iligan City
Hospital/Home/Lying-in, Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CRISTINA L. JAYSON


Date Performed
and
Time Started

Patients INITIAL Only

Case Number
(not applicable for Birthing/Lying-in
Clinics/Homes)

SURGICAL PROCEDURE
PERFORMED


O.R. Nurse on Duty
(Name and Signature)


SUPERVISED BY
Clinical Instructor
Name and Signature

August 9, 2012
11:30 PM

RB
147899

Appendectomy

Jed R. Santos, RN, CRN
PRC Number: 0660385
Valid Until: July 14, 2016

Darilyn G. Literatus, MN, RN
PRC Number: 0301632
Valid Until: November 25, 2016

September 13, 2012
11:32 AM


SB
130179

Pelvic Laparotomy

Wendy Mar S. Rodrigo, RN
PRC Number: 0313886
Valid Until: March 3, 2015

Sheilma Dreamy G. Manata, MN,RN
PRC Number: 0173264
Valid Until: May 28, 2017

December 6, 2012
1:40 PM

JG
062232

First Repeat Low Segment
Transverse Cesarean Section

Belen Joy C. Patindol, RN
PRC Number: 0306764
Valid Until: December 20, 2015

Sheilma Dreamy G. Manata,MN, RN
PRC Number: 0173264
Valid Until: May 28, 2017


Noted by: EVALYN M. LECCIONES, MN, RN Approved by: GTER G, GAID, PhD, MAN, RN N
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.: 0245303 Valid Until:May 9, 2015 Dean, PRC I.D. No.:0302269 Valid Until: September 13, 2015
Date document is signed: ________ Time:______________ Date document is signed: Time: ____________________
Please specify Highest Nursing Degree Earned: Master in Nursing Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
O.R. Form 1A
O.R. SCRUB FORM
MAJOR