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ODC Form 4

Republic of the Philippines


AMANDO COPE COLLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007

IMMEDIATE
NEWBORN
CORD CARE

IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: KAIZIRIN O. SALINAS

Patients INITIALS
(only)
Date Performed and
Time Started

Noted by:

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

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________

D.R. Nurse / Midwife On


Duty
(Name Only)

Approved by:

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN


(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________

Please specify Highest Nursing Degree Earned: MAN

Please specify Highest Nursing Degree Earned: MAN,


PhD Form 4
ODC
Republic of the Philippines
IMMEDIATE
AMANDO COPE COLLEGE
NEWBORN
CORD
CARE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007

IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: AICCA REANNA S. DESIPEDA

Patients INITIALS
(only)
Date Performed and
Time Started

Noted by:

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

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse / Midwife On


Duty
(Name Only)

Approved by:

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN


(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:

Date document is signed: _________________ Time: ____________


Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN
Please specify Highest Nursing Degree Earned: MAN,
PhD Form 4
ODC
Republic of the Philippines
IMMEDIATE
AMANDO COPE COLLEGE
NEWBORN
CORD CARE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: MARY JOY V. COPINO

Patients INITIALS
(only)
Date Performed and
Time Started

Noted by:

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

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse / Midwife On


Duty
(Name Only)

Approved by:

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN


(Printed Name and Signature)

Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:


Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ____________
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN
Please specify Highest Nursing Degree Earned: MAN,
PhD Form 4
ODC
Republic of the Philippines
IMMEDIATE
AMANDO COPE COLLEGE
NEWBORN
CORD
CARE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: ANGELA B. COPE

Patients INITIALS
(only)
Date Performed and
Time Started

Noted by:

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

VILMA U. BORLAGDAN, RN

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse / Midwife On


Duty
(Name Only)

Approved by:

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)


(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until: 10.30.2014
Dean, PRC I.D. No. 0090644
Valid Until: 5.30.2015
Date document is signed: _________________ Time: ____________
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN
Please specify Highest Nursing Degree Earned: MAN,
PhD Form 4
ODC
Republic of the Philippines
IMMEDIATE
AMANDO COPE COLLEGE
NEWBORN
CORD CARE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: GINA R. CARULLO

Patients INITIALS
(only)
Date Performed and
Time Started

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

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse / Midwife On


Duty
(Name Only)

SUPERVISED BY
Clinical Instructor
Name and Signature

Noted by:

VILMA U. BORLAGDAN, RN
Approved by:
MARIA RENEE O. COPE, RN
(Printed Name and Signature)
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ____________
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN
Please specify Highest Nursing Degree Earned: MAN,
PhD Form 4
ODC
Republic of the Philippines
IMMEDIATE
AMANDO COPE COLLEGE
NEWBORN
CORD CARE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: JAMELA FAYE M. BAYABAN

Patients INITIALS
(only)
Date Performed and
Time Started

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

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse / Midwife On


Duty
(Name Only)

SUPERVISED BY
Clinical Instructor
Name and Signature

Noted by:

VILMA U. BORLAGDAN, RN
Approved by:
MARIA RENEE O. COPE, RN
(Printed Name and Signature)
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ____________
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN
Please specify Highest Nursing Degree Earned: MAN,
PhD Form 4
ODC
Republic of the Philippines
IMMEDIATE
AMANDO COPE COLLEGE
NEWBORN
CORD
CARE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
IMMEDIATE NEWBORN CORD CARE in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student: MARLA F. ARANDELA

Patients INITIALS
(only)
Date Performed and
Time Started

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

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse / Midwife On


Duty
(Name Only)

SUPERVISED BY
Clinical Instructor
Name and Signature

Noted by:

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

Approved by:

MARIA RENEE O. COPE, RN


(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD