UNIVERSITY OF PANGASINAN

PHINMA Education Network
College of Nursing
Dagupan City

1

2

Name of Patient:

Name of Patient:

___________________________________________

___________________________________________

Address: ___________________________________

Address: ___________________________________

Age: _______________ Case No: _______________

Age: _______________ Case No: _______________

Gravida: ____________ Para: __________________

Gravida: ____________ Para: __________________

Date of Delivery: ____________________________

Date of Delivery: ____________________________

Gender of Baby: _____________________________

Gender of Baby: _____________________________

STUDENT NUMBER:

Time of Delivery: ____________________________

Time of Delivery: ____________________________

___________________________________________

Type of Delivery: ____________________________

Type of Delivery: ____________________________

Diagnosis:

Diagnosis:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Obstetrician: ________________________________

Obstetrician: ________________________________

____________________ _____________________

____________________ _____________________

ACTUAL CASE SLIP
NAME OF STUDENT:

PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN
CLINICAL COORDINATOR

PRC NO: 0133422
VALID UNTIL: July 27, 2011

.
.

PNA NO:
VALID UNTIL:

.
.

ANSAP NO:
VALID UNTIL:

.
.

Staff Nurse on Duty

Nurse Instructor

Staff Nurse on Duty

Nurse Instructor

PRC No. __________

PRC No. ___________

PRC No. __________

PRC No. ___________

Agency:

Agency:

___________________________________________

___________________________________________

3

4

5

Name of Patient:

Name of Patient:

Name of Patient:

___________________________________________

___________________________________________

___________________________________________

Address: ___________________________________

Address: ___________________________________

Address: ___________________________________

Age: _______________ Case No: _______________

Age: _______________ Case No: _______________

Age: _______________ Case No: _______________

Gravida: ____________ Para: __________________

Gravida: ____________ Para: __________________

Gravida: ____________ Para: __________________

Date of Delivery: ____________________________

Date of Delivery: ____________________________

Date of Delivery: ____________________________

Gender of Baby: _____________________________

Gender of Baby: _____________________________

Gender of Baby: _____________________________

Time of Delivery: ____________________________

Time of Delivery: ____________________________

Time of Delivery: ____________________________

Type of Delivery: ____________________________

Type of Delivery: ____________________________

Type of Delivery: ____________________________

Diagnosis:

Diagnosis:

Diagnosis:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Obstetrician: ________________________________

Obstetrician: ________________________________

Obstetrician: ________________________________

____________________ _____________________

____________________ _____________________

____________________ _____________________

Staff Nurse on Duty

Nurse Instructor

Staff Nurse on Duty

Nurse Instructor

Staff Nurse on Duty

Nurse Instructor

PRC No. __________

PRC No. ___________

PRC No. __________

PRC No. ___________

PRC No. __________

PRC No. ___________

Agency:

Agency:

Agency:

___________________________________________

___________________________________________

___________________________________________

UNIVERSITY OF PANGASINAN
PHINMA Education Network
College of Nursing
Dagupan City

1

2

Name of Patient:

Name of Patient:

___________________________________________

___________________________________________

Address: ___________________________________

Address: ___________________________________

Age: _______________ Case No: _______________

Age: _______________ Case No: _______________

Gravida: ____________ Para: __________________

Gravida: ____________ Para: __________________

Date of Delivery: ____________________________

Date of Delivery: ____________________________

Gender of Baby: _____________________________

Gender of Baby: _____________________________

STUDENT NUMBER:

Time of Delivery: ____________________________

Time of Delivery: ____________________________

___________________________________________

Type of Delivery: ____________________________

Type of Delivery: ____________________________

Diagnosis:

Diagnosis:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Obstetrician: ________________________________

Obstetrician: ________________________________

____________________ _____________________

____________________ _____________________

ASSISTED CASE SLIP
NAME OF STUDENT:

PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN
CLINICAL COORDINATOR

PRC NO: 0133422
VALID UNTIL: July 27, 2011

.
.

PNA NO:
VALID UNTIL:

.
.

ANSAP NO:
VALID UNTIL:

.
.

Staff Nurse on Duty

Nurse Instructor

Staff Nurse on Duty

Nurse Instructor

PRC No. __________

PRC No. ___________

PRC No. __________

PRC No. ___________

Agency:

Agency:

___________________________________________

___________________________________________

3

4

5

Name of Patient:

Name of Patient:

Name of Patient:

___________________________________________

___________________________________________

___________________________________________

Address: ___________________________________

Address: ___________________________________

Address: ___________________________________

Age: _______________ Case No: _______________

Age: _______________ Case No: _______________

Age: _______________ Case No: _______________

Gravida: ____________ Para: __________________

Gravida: ____________ Para: __________________

Gravida: ____________ Para: __________________

Date of Delivery: ____________________________

Date of Delivery: ____________________________

Date of Delivery: ____________________________

Gender of Baby: _____________________________

Gender of Baby: _____________________________

Gender of Baby: _____________________________

Time of Delivery: ____________________________

Time of Delivery: ____________________________

Time of Delivery: ____________________________

Type of Delivery: ____________________________

Type of Delivery: ____________________________

Type of Delivery: ____________________________

Diagnosis:

Diagnosis:

Diagnosis:

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

___________________________________________

Obstetrician: ________________________________

Obstetrician: ________________________________

Obstetrician: ________________________________

____________________ _____________________

____________________ _____________________

____________________ _____________________

Staff Nurse on Duty

Nurse Instructor

Staff Nurse on Duty

Nurse Instructor

Staff Nurse on Duty

Nurse Instructor

PRC No. __________

PRC No. ___________

PRC No. __________

PRC No. ___________

PRC No. __________

PRC No. ___________

Agency:

Agency:

Agency:

___________________________________________

___________________________________________

___________________________________________

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