WORLD CITI COLLEGES

960 Aurora Blvd., Cubao Quezon City

Tel. # 9138380 Fax # 9138380 Local 421
E-mail Address: info@worldciti.educ.ph Web-Site www.worldciti.edu.ph

ACTUAL DELIVERY in _____BATASAN LYING-IN , QUEZON CITY______

Hospital/Home/Lying-In Clinic, Municipality/City/Province
D.R. Form
Prepared by: ACTUAL DELIVERY FORM
Print Name and Signature of Student FERNANDEZ, GLABRION URIEL

Date Performed Patient’s INITIAL Only D.R. Nurse On Duty

SUPERVISED BY
and Case Number PROCEDURE (Name and Signature)
Clinical Instructor
Time Started (not applicable for Birthing/Lying-in PERFORMED (If Midwife on Duty, signature not
Name and Signature
Clinics/Homes) required

September 28, 2017 G.C.

Normal Spontaneous Delivery Janette L. Galarpe, RM Jenny R. San Juan, RN, MAN
7:20 PM #19497

October 05, 2017 C.D.

Normal Spontaneous Delivery Rachel J. Limpin, RM Jenny R. San Juan, RN, MAN
3:30 PM #19578

October 12, 2017 M.A.

Normal Spontaneous Delivery Janette L. Galarpe, RM Jenny R. San Juan, RN, MAN
3:02 PM #19543

(STRICTLY NO DESIGNATES)
(These Forms must be printed at the back of the 1 st page of the Competency-Based Performance Evaluation Checklist)
 WORLD CITI COLLEGES
960 Aurora Blvd., Cubao Quezon City
Tel. # 9138380 Fax # 9138380 Local 421
E-mail Address: info@worldciti.educ.ph Web-Site www.worldciti.edu.ph

IMMEDIATE NEWBORN CORD CARE in __ _ BATASAN LYING-IN , QUEZON CITY_________

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by: ICNB Form

Print Name and Signature of Student FERNANDEZ, GLABRION URIEL IMMEDIATE CARE OF THE NEWBORN FORM

Patient’s INITIAL Only Immediate Newborn Cord Care

Date Performed Nurse On Duty
PERFORMED SUPERVISED BY
and Case Number (Name and Signature)
Indicate where performed e.g. Clinical Instructor
Time Started (not applicable for Birthing/Lying-in (If Midwife on Duty, signature not
D.R.., Nursery, Name and Signature
Clinics/Homes) required)
NICU, or Home
September 09, 2017 S.D.S.
Delivery Room Asha D. Estate, RM Jenny R. San Juan, RN, MAN
3:35 PM #19504

October 06, 2017 E.P.

Delivery Room Remilyn S. Eguia, RM Jenny R. San Juan, RN, MAN
2:46 PM #19526

October 13, 2017 N.M.

Delivery Room Jenefer R. Villanueva, RM Jenny R. San Juan, RN, MAN
7:15 PM #19571

(STRICTLY NO DESIGNATES)
(These Forms must be printed at the back of the 1 st page of the Competency-Based Performance Evaluation Checklist)