MANILA TYTANA COLLEGES

Formerly, Manila Doctors College

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City
Tel. No. (02)859-0859-0812/ Fax No. (02) 859-0875
PAASCU Level II Re-Accredited Status, November 2011-November 2016

SURGICAL SCUB IN

OR SCRUB FORM 1A
O.R. SCRUB FORM
MAJOR

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student
Date Performed
Patients Initial (only)
And
Case Number
Time Started

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty

(Name and Signature)

OR CIRCULATING IN JUSTICE JOSE ABAD SANTOS GENERAL HOSPITAL, BINONDO MANILA

Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _ MA. LYKA ANDREA S. PUNO _______________
Date Performed
And
Time Started
September 13, 2012
1130H
September 21, 2012
0830H

Patients Initial (only)

Case Number

SURGICAL PROCEDURE
PERFORMED

531019
A.D.
291139
M.E.

Appendectomy

O.R. Nurse On Duty

(Name and Signature)

O.R. Nurse On Duty

(Name and Signature)

OR SCRUB FORM 1A
O.R. CIRCULATING
MAJOR
SUPERVISED BY
Clinical Instructor
(Name and Signature)

Marie Kathleen Castro, RN

DENNIS SISON , RN, MAN

Heniorrhapy with mesh

Right Inguinal

Alyssa Katrina Liongson, RN

(This form must be printed at the back of the 1st page of the Competency Based Performance Evaluation Checklist prescribed by BON)

DENNIS SISON , RN, MAN