FOUNDATION UNIVERSITY

COLLEGE OF NURSING
Dr. Miciano Road, DUMAGUETE CITY 6200
Tel. No.: (035)422-9167 Local 110
Fax No.: (035) 225-0617 Email: cn@foundationu.com
Surgical Scrub in NEGROS ORIENTAL PROVINCIAL HOSPITAL, Dumaguete City Negros Oriental

ODC Form 2A
OR Scrub Form
MAJOR

Prepared by: _____________________

Date Performed
&
Time Started

Patients Initial only

Case number

Noted By: Melanie Mae O. Austero BSN-RN, MAEd, MN,

Clinical Coordinator, PRC No.0327055 Valid Until April 12, 2015
Date Document is signed ____________ Time _____________
Please Specify Highest Nursing Degree Earned: Master in Nursing

Surgical Procedure
Performed

O.R. Nurse on Duty

(Name & Signature)

Supervised by
Clinical Instructor
(Name & Signature)

Approved By: Nenita P. Tayko, RN, MAN

Dean, PRC No.0017583 Valid Until July 16, 2015
Date Document is Signed ____________ Time _________
Please Specify Highest Degree Earned: Master of Arts in Nursing

FOUNDATION UNIVERSITY
COLLEGE OF NURSING
Dr. Miciano Road, DUMAGUETE CITY 6200
Tel. No.: (035)422-9167 Local 110
Fax No.: (035) 225-0617 Email: cn@foundationu.com
Surgical Scrub in NEGROS ORIENTAL PROVINCIAL HOSPITAL, Dumaguete City Negros Oriental

ODC Form 2A
OR Scrub Form
MINOR

Prepared by: _____________________

Date Performed
&
Time Started

Patients initial only

Case number

Noted By: Melanie Mae O. Austero BSN-RN, MAEd, MN,

Clinical Coordinator, PRC No.0327055 Valid Until April 12, 2015
Date Document is signed ____________ Time _____________
Please Specify Highest Nursing Degree Earned: Master in Nursing

Surgical Procedure
Performed

E.R. /O.R. Nurse on Duty

(Name & Signature)

Supervised by Clinical Instructor

(Name & Signature)

Approved By: Nenita P. Tayko, RN, MAN

Dean, PRC No.0017583 Valid Until July 16, 2015
Date Document is Signed ____________ Time _________
Please Specify Highest Degree Earned: Master of Arts in Nursing

FOUNDATION UNIVERSITY
COLLEGE OF NURSING
Dr. Miciano Road, DUMAGUETE CITY 6200
Tel. No.: (035)422-9167 local 110
Fax No.: (035) 225-0617 Email: cn@foundationu.com
Actual Deliveries in NEGROS ORIENTAL PROVINCIAL HOSPITAL, Dumaguete City Negros Oriental

ODC Form 1A
Actual Delivery
Form

Prepared by: ________________

Date Performed
&
Time Started

Patients initial
only

Procedure Performed

Case number

D.R. Nurse on Duty

(Name & Signature)

Supervised by Clinical Instructor

(Name & Signature)

Handled

Handled

Handled

Handled

Handled

Noted By: Melanie Mae O. Austero BSN-RN, MAEd, MN,

Clinical Coordinator, PRC No.0327055 Valid Until April 12, 2015
Date Document is signed ____________ Time _____________
Please Specify Highest Nursing Degree Earned: Master in Nursing

Approved By: Nenita P. Tayko, RN, MAN

Dean, PRC No.0017583 Valid Until July 16, 2015
Date Document is Signed ____________ Time _________
Please Specify Highest Degree Earned: Master of Arts in Nursing

FOUNDATION UNIVERSITY
COLLEGE OF NURSING
Dr. Miciano Road, DUMAGUETE CITY 6200
Tel. No.: (035)422-9167 Local 110
Fax No.: (035) 225-0617 Email: cn@foundationu.com
Assisted Deliveries in NEGROS ORIENTAL PROVINCIAL HOSPITAL, Dumaguete City, Negros Oriental

ODC Form 1B
Assisted Delivery
Form

Prepared by: _______________

Date Performed
&
Time Started

Patients initial only

Procedure Performed
Case number

D.R. Nurse on Duty

(Name & Signature)

Supervised by Clinical Instructor

(Name & Signature)

Assist

Assist

Assist

Assist

Assist

Noted By: Melanie Mae O. Austero BSN-RN, MAEd, MN,

Clinical Coordinator, PRC No.0327055 Valid Until April 12, 2015
Date Document is signed ____________ Time _____________
Please Specify Highest Nursing Degree Earned: Master in Nursing

Approved By: Nenita P. Tayko, RN, MAN

Dean, PRC No.0017583 Valid Until July 16, 2015
Date Document is Signed ____________ Time _________
Please Specify Highest Degree Earned: Master of Arts in Nursing

FOUNDATION UNIVERSITY
COLLEGE OF NURSING
Dr. Miciano Road, DUMAGUETE CITY 6200
Tel. No.: (035)422-9167 Local 110
Fax No.: (035) 225-0617 Email: cn@foundationu.com
Immediate Newborn Care in NEGROS ORIENTAL PROVINCIAL HOSPITAL, Dumaguete City, Negros Oriental

ODC Form 1C
Cord Care
Form

Prepared by: ______________________

Date Performed
&
Time Started

Patients initial only

Procedure Performed
Case number

D.R. Nurse on Duty

(Name & Signature)

Supervised by Clinical Instructor

(Name & Signature)

Initial Care of the Newborn

Initial Care of the Newborn

Initial Care of the Newborn

Initial Care of the Newborn

Initial Care of the Newborn

Noted By: Melanie Mae O. Austero BSN-RN, MAEd, MN,

Clinical Coordinator, PRC No.0327055 Valid Until April 12, 2015
Date Document is signed ____________ Time _____________
Please Specify Highest Nursing Degree Earned: Master in Nursing

Approved By: Nenita P. Tayko, RN, MAN

Dean, PRC No.0017583 Valid Until July 16, 2015
Date Document is Signed ____________ Time _________
Please Specify Highest Degree Earned: Master of Arts in Nursing