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As adopted by Far Eastern University- Dr.

Nicanor Reyes Medical Foundation School of Nursing
ODC Form 2A
O.R. SCRUB
FORM
Far Eastern University- Dr. Nicanor Reyes Medical Foundation MAJOR
Regalado Avenue, near Dahlia Street, West Fairview, Quezon City, Philippines 1118
Tel. 427- 0213 Loc. 1147/ Website: www.feu-nrmf.edu.ph
with Government Recognition No. 046 Series OF 2007, CHED (Per CEB Resolution Number 229- 2007)
SURGICAL SCRUB in Far Eastern University – Dr. Nicanor Reyes Medical Foundation/ Regalado Avenue, West Fairview, Quezon City

Prepared by: _____DARYL HERMINIGILDO RAMOS Student Number: ___2007AN218___
(Printed Name and Signature of Student)

Patient’s Initial
Date Performed Only SURGICAL PROCEDURE O.R. Nurse On Duty Signature Supervised by Signature
and PERFORMED (Clinical Instructor)
Time Started Case Number

July 08, 2009 L.H.C. Extra-fascial Hysterectomy OMAR K. LUIS, R.N. DOREEN M. CERVANTES,
07:00AM 24646 Bilateral Salphingo- R.N., M.A.N.
Oophorectomy
January 11, 2010 R.D.S. Excess Biopsy with Frozen DOREEN MANARPIIS, R.N. DOREEN M. CERVANTES,
07:00AM 32178 Section Modified Radical R.N., M.A.N.
Mastectomy
June 23, 2010 A.F.M. Reversal of Hartmann’s FELLE ADELITZ GERARDINE D. JOSAN M. REYES, R.N.,
08:20AM 34255 Procedure SAMALA, R.N. M.A.N.
June 29, 2010 L.J.B. Total Thyroidectomy AARON ADRIANO, R.N. JOSAN M. REYES, R.N.,
09:05AM 34406 M.A.N.
June 29, 2010 L.M.C. Phacoemulsification with FELLE ADELITZ GERARDINE D. JOSAN M. REYES, R.N.,
01:15PM 062110 Posterior Chamber SAMALA, R.N. M.A.N.
Intraocular Lens, Right Eye

Noted by: Approved by:

TRINA C. TAN, RN, MAN TITA YAP- CRUZ, RN, MAN, Ed. D.
Clinical Coordinator Dean, School of Nursing
PRC ID. No. ___________ Valid Until _______________________ PRC ID. No. _____38788_____ Valid Until _September 29,
2011__
Date Documented is signed: ____________________________ Date Documented is signed: _____________________________

N. CERVANTES. 10:20 AM 32274 (Titanium Plates and R. M. R. 1147/ Website: www. R. MELANIE GRACE S.0213 Loc. R. MINOR FORM Far Eastern University. 2010 L. RN. Nicanor Reyes Medical Foundation School of Nursing ODC Form 2B O.P. Right Upper Lid EVELYN ALBANIA.N.N.Dr. Screws) March 08.A. TAN.D. M.N.Dr. Excision of M. M. Removal of Internal Fixation CHARISSE CANDELARIA.A.A.N JOSAN M. West Fairview. 08:35AM 34236 Plasty. RN.N. As adopted by Far Eastern University. Jr. Chalazion.. 11:30 AM 10-00194 Status Post Incision and FRANCISCO.A. R.N.. Nicanor Reyes Medical Foundation/ Regalado Avenue. Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN. Curettage.N.CRUZ.C.N. REYES. Release of Trigger Finger EVELYN ALBANIA. 09:00 AM 10-00206 Preauricular Area.R. R. Multiple Acrocordon both EVELYN ALBANIA.A. 427. Ed. R. Nicanor Reyes Medical Foundation Regalado Avenue. MELANIE GRACE S.. Philippines 1118 Tel.R. Nurse On Duty Signature Supervised by Signature and PERFORMED (Clinical Instructor) Time Started Case Number January 13.N. Open Rhinoplasty with Tip CHARISSE CANDELARIA. MELANIE GRACE S.ph with Government Recognition No. 2010 A.R. near Dahlia Street. D. Excision FRANCISCO. 046 Series OF 2007.J. 2010 I.edu.2007) SURGICAL SCRUB in Far Eastern University – Dr. 2010 J.. R. 2010 M. Right Upper Lid March 10. Ed..D.N. West Fairview. Quezon City.N. MAN.D.N. M. CHED (Per CEB Resolution Number 229.N.N. Biopsy March 17.A.T. DOREEN M. .feu-nrmf. MAN TITA YAP. 01:30 PM 10-00223 FRANCISCO. Siliconoma with Biopsy Noted by: Approved by: TRINA C.A.N. June 22.F. R. R. Quezon City Prepared by: _____DARYL HERMINIGILDO RAMOS_____ Student Number: ___2007AN218___ (Printed Name and Signature of Student) Patient’s Initial Date Performed Only SURGICAL PROCEDURE O.

Clinical Coordinator Dean. School of Nursing PRC ID. ___________ Valid Until _______________________ PRC ID. No. 2011__ Date Documented is signed: ____________________________ Date Documented is signed: _____________________________ Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN. No. _____38788_____ Valid Until _September 29. D . Ed.