University of Cebu

College of Nursing – Banilad Campus
Governor Cuenco Avenue, Banilad
Cebu City

Page 1 of 10
Name of Student: _____________________________________________________________________________________________________________________________________________________________
Name & Address of School: _University of Cebu - Banilad Governor Cuenco Avenue, Banilad, Cebu City_________________________________________________________________________________________________________
________
Accreditation Level (if any): _Level II – Third Reaccredited Status________________________________________________ Year Granted: 2007_____________________________________________________________________________
First Course (if any): ____________________________________________________________________________________ School Graduated From: ________________________________ Year: _______________________________
Year of Admission in the Bachelor of Science in Nursing Program: ____________________________________________________________________________________________________________________________________________
Year Graduated (BSN Program): _2009____________________________________________________________________________________________________________________________________________________ ________________
I. Major Operations
No
.

Date of
Operation

Case No.

Name of Patient

Diagnosis

Operation Performed

Type of
Anesthesia

Name of Surgeon

Name of Hospital

Name of O.R.
Scrub Nurse

1

1/27/2006

93202

Princess Borja

Epidermal Inclusion Cyst

Excision of Anterior
Neck Mass, Neck
Exploration

General

Don Enrico P.
Garcia, M.D.

Chong Hua
Hospital

Eileen Gail O.
Florendo, R.N.

Cholecystectomy
with Intraoperative
Cholangiogram,
Common Bile Duct
Exploration with Ttube Insertion

General

Achilles M. Cortes,
M.D.

2

2/2/2006

93771

Warren N. Holganza

Cholecystitis Hydrop Gallbladder
Secondary to Stone at Cystic
Duct, Cholestorolosis

3

2/3/2006

93850

Eleonor N. Plasus

Ductal Carcinoma Breast, Right

Modified Radical
Mastectomy, Right

General

Rogelio G.
Kangleon Jr., M.D.

Chong Hua
Hospital

General

Kenneth S. Chan,
M.D.

Chong Hua
Hospital

Regional

Iben A. Ting, M.D.

4

2/9/2006

94560

Ailil Ailette T. Phua

Endometriosis

Exploratory
Laparotomy
Sigmoidectomy with
End to End
Anastomosis, Frozen
Section

5

2/10/2006

94448

Roland C. Co

Acute Appendicitis

Appendectomy

Prepared by:

Name of Student

_

Chong Hua
Hospital

Chong Hua
Hospital

Marga Rita M.
Esperanza, R.N.

Eileen Gail O.
Florendo, R.N.

Sheila Niña A.
Basa, R.N.

Montzheimer C.
Preagido, R.N.

Signature of
O.R. Scrub
Nurse

: ______________________ Valid until: _______________________ DR. ESTELLA P.) PNA No. rules and regulations of the Republic of the Philippines. 2011_____________ b. HELEN C. DM____________________ a. NOTARY PUBLIC .) PRC No.: ____________________ Valid until: ____________________ b.) ADCPN No. VILLEGAS_________ Signature over printed name of Clinical Coordinator Date Signed: _____________________________ Degree: MAN_____________________________ a.) PNA No.: 2764_____________________ Valid until: Lifetime__________________ c. _______________________________________ Signature of Applicant Subscribed and sworn to before me this _______ day of ___________________________ 20 ____.: ‘0034689_______________________ Valid until: June 15. PILUCHI VICTORINA M.) PNA No.: _443__________________________ Valid until: _Lifetime______________________ (NAME OF CHIEF NURSE)___________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _ _______________________ a.) PRC No.Supervised by: Noted by: Concurred by: Approved by: MS. correct.: ________________________ Valid until: ________________________ c. and complete statement pursuant to the provisions of pertinent laws. _________________________________________. verified by me and to the best of my knowledge and belief is a true.) ANSAP No. ESTRELLA_____________ Signature over printed name of Dean Date Signed: ________________________ Degree: _MN. CABATANA______ Signature over printed name of Faculty Date Signed: ____________________ Degree: _MN__________________ a.) PRC No. Philippines. MA.: ________________________ Valid until: ________________________ b.) PRC No.: ‘0075238_________________ Valid until: June 19.: 154____________________ Valid until: ___________________ I declare under oath that these cases had been accomplished by me in good faith. 2012__________________ b.: ____________________ Valid until: ____________________ MS.) PNA No.

Chong Hua Hospital BJ C.University of Cebu College of Nursing – Banilad Campus Governor Cuenco Avenue.R. Date of Operation Case No. M. 5 2/9/2007 127494 Joey E. R. M. Banilad. R. Migallos. M. Yapha.R.N.N.N. Subscapular Area. Fernandez.N. Severo Verallo Memorial Hospital Liezel P. Severo Verallo Memorial Hospital Liezel P.D. Fernandez. Lanurias Perineal Laceration Episiorrhaphy Local Mario M. M. Nasal Cavity. Banilad Cebu City Page _3_ of _10_ Name of Student: ____________________________________________________________________________________________________________________________________________ ________________ Name & Address of School: _ University of Cebu . Prepared by: Name of Student Lymphoma Subscapular Area. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name of O. 3 8/31/2006 112364 Ma. Scrub Nurse . 4 9/7/2006 503555 Caridad Alipuyo Excision of Mass. Right. R.D. 2 7/6/2006 045603 Alona E. Seredrica.Banilad Governor Cuenco Avenue. Baldoza. Left Genital Warts Signature of O.D. R. Angot. Cebu City _________________________________________________________________________________________________________ Accreditation Level (if any): ___________________________________________________________ Year Granted: ________________________________________________________________________ ________ First Course (if any): ____________________________________________________________________________________ School Graduated From: ________________________________ Year: _______________________________ Year of Admission in the Bachelor of Science in Nursing Program: ___________________________________________________________________________________________________________________________________________ Year Graduated (BSN Program): __________________________________________________________________________________________________________________________________________________________________ II. Left Local Geraldine P.D. Scrub Nurse 1 7/6/2006 06-66-77 Melody Metante Sebaceous Cyst Infected Chest Excision of Sebaceous Cyst Local Mario M. Melencion Cauterization of Genital Warts Regional Jose Rizalito C.N. Lugue Inverting Papilloma. R. Visayas Community Medical Center Gail Vera E. Chong Hua Hospital Lorelei G. Minor Operations No .D. Baldoza. M. Theresa Y. Maco. Catipay. Status Post Punch Biopsy Medial Maxillectomy Right General Gina M.

) PRC No.: ‘0034689_______________________ Valid until: June 15.) ADCPN No.: ____________________ Valid until: ____________________ MS.: ______________________ Valid until: _______________________ (NAME OF CHIEF NURSE)____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a.: ________________________ Valid until: ________________________ c.:11659_____________________ Valid until: 4/14/2007________________ c.: ______________________ Valid until: _______________________ DR.) ANSAP No.:_0173592__________________ Valid until: May 28. verified by me and to the best of my knowledge and belief is a true. and complete statement pursuant to the provisions of pertinent laws.) PNA No.) PRC No.) PRC No.: ________________________ Valid until: ________________________ b.) PRC No.: ________________________ Valid until: ________________________ b.: 2764____________________ Valid until: Lifetime_________________ c. PILUCHI VICTORINA M. rules and regulations of the Republic of the Philippines. 2009__________________ b. HELEN C.) PNA No.) ANSAP No. ESTELLA P. Philippines. NOTARY PUBLIC . correct.) PNA No.) PNA No.) PNA No.: ____________________ Valid until: ____________________ b. 2008_____________ b. ESTRELLA ____________ Signature over printed name of Dean Date Signed: ________________________ Degree: _MN.) PRC No.: ‘0075238_________________ Valid until: June 19. _______________________________________ Signature of Applicant Subscribed and sworn to before me this _______ day of ___________________________ 20 ____.) PNA No. _________________________________________. VILLEGAS_______ Signature over printed name of Clinical Coordinator Date Signed: _____________________________ Degree: _________________________________ a.: _443__________________________ Valid until: _Lifetime______________________ (NAME OF CHIEF NURSE)____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a.Supervised by: Noted by: Concurred by: Concurred by: MS. 2009_____________ b.) ANSAP No.) PRC No. MAN___________________ a. CABATANA __ Signature over printed name of Faculty Date Signed: ____________________ Degree: _MN___________________ a. MA.: 154____________________ Valid until: 2007____________________ I declare under oath that these cases had been accomplished by me in good faith.: ________________________ Valid until: ________________________ c.: ______________________ Valid until: _______________________ Concurred by: Approved by: (NAME OF CHIEF NURSE)_____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a.

Mauro Allan P. RN. RN. Actual Deliveries No . Mauro Allan P. MAN 3 06-09021 Pregnancy Uterine Full Term Age of Gestation: 40 weeks and 5 days Flordeliza Deiparine 29 11/9/2006 5:55 AM Female Minglanilla District Hospital Normal Spontaneous Vaginal Delivery Mr. Banilad Cebu City Page _5_ of 10_ Name of Student: _ __________________________________________________________________________________________________________________________________________________________________________ Name & Address of School: _ University of Cebu .I. Diagnosis Name of Mother Age Date of Delivery Time of Delivery Gender of Baby Name of Hospital Type of Delivery Supervised by: Name & Signature of Qualified C. Cebu City _____________________________________________________________________________________________________________ Accreditation Level (if any): _ ____________________________________________________________ Year Granted: _______________________________________________________________________________ First Course (if any): ____________________________________________________________________________________ School Graduated From: ________________________________ Year: _______________________________ Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________________________________________________________________________________ Year Graduated (BSN Program): __________________________________________________________________________________________________________________________________________________________________ III. Amparado. Case No. MAN Prepared by: GARCIA. Amparado. MAN 2 03118 Pregnancy Uterine Full Term Age of Gestation: 44 weeks and 2 days Miguela M. MAN 5 07-28921 Pregnancy Uterine Full Term Age of Gestation: 42 weeks and 5 days Lucina Juntilla 33 4/8/2007 5:05 AM Female Danao District Hospital Normal Spontaneous Vaginal Delivery Mr. 1 105685 Pregnancy Uterine Full Term Age of Gestation: 38 weeks and 4 days Gemma Comajes 36 8/12/2005 8:42 AM Male Visayas Community Medical Center Normal Spontaneous Vaginal Delivery Mr. Mauro Allan P. Mauro Allan P. RN. RN. JOHN C Name of Student . Amparado. Tumulak 36 10/13/200 5 4:20 PM Male Lapu-lapu District Hospital Normal Spontaneous Vaginal Delivery Mr. Jumao-as 32 1/18/2007 3:20 PM Female Visayas Community Medical Center Normal Spontaneous Vaginal Delivery Mr.University of Cebu College of Nursing – Banilad Campus Governor Cuenco Avenue. Banilad. RN. Amparado. Amparado. MAN 4 286539 Pregnancy Uterine Full Term Age of Gestation: 37 weeks and 6 days Chona L. Mauro Allan P.Banilad Governor Cuenco Avenue.

) PNA No. Grace C.: ‘0307204__________________ Valid until: March 3.) PNA No.) PNA No. 2009__________________ b. 2008____________ b.:_213_____________________ Valid until:_lifetime_________________ Concurred by: Concurred by: Approved by: Mrs. correct.: ‘0034689_______________________ Valid until: June 15. Monsanto_______________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a. verified by me and to the best of my knowledge and belief is a true. Evelyn J.: ______________________ Valid until: _______________________ Dr.: ________________________ Valid until: ________________________ b.:_0043828__________________ Valid until: December 2010____________ b.: 154____________________ Valid until: 2007____________________ I declare under oath that these cases had been accomplished by me in good faith.: _443__________________________ Valid until: _Lifetime______________________ __ Concurred by: Concurred by: (NAME OF CHIEF NURSE)_____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a.: ‘0075238_________________ Valid until: June 19.) ANSAP No. APUHIN Signature over printed name of Faculty Date Signed: _________________________ Degree: _MAN________________________ a. _________________________________________. _______________________________________ Signature of Applicant Subscribed and sworn to before me this _______ day of ___________________________ 20 ____. 2009_____________ b.:_0173592_________________ Valid until: May 28.: ________________________ Valid until: ________________________ b.: ______________________ Valid until: _______________________ Mrs.) PRC No.) PNA No.:11659____________________ Valid until: 4/14/2007________________ c. Estremos_______________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a. 2010_____________ b. Josifina A.) PRC No. rules and regulations of the Republic of the Philippines.) PRC No.) PNA No. NOTARY PUBLIC University of Cebu College of Nursing – Banilad Campus .Supervised by: Noted by: MRS. DM____________________ a.) ANSAP No.) ANSAP No.: 16223_____________________ Valid until: MS.: ________________________ Valid until: ________________________ c.: ________________________ Valid until: ________________________ c.) PRC No.) PNA No. VILLEGAS Signature over printed name of Clinical Coordinator Date Signed: _____________________________ Degree: _________________________________ a.:___________________________ Valid until:__________________________ c.) PRC No. Helen C. Empaces___________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _MAN_______________________ a.) PRC No.: ______________________ Valid until: _______________________ Mrs. and complete statement pursuant to the provisions of pertinent laws.Estrella___________________ Signature over printed name of Dean Date Signed: ________________________ Degree: _MN.) PNA No.: 2764_____________________ Valid until: Lifetime__________________ c. PILUCHI VICTORINA M.) ADCPN No. Philippines.) PRC No.) ANSAP No. MERCY MILAGROSB.

RN.: ‘0034689_______________________ Valid until: June 15.) PRC No. PILUCHI VICTORINA M..: Valid until: ______________ b. Banilad.) ANSAP No. MAN 3 06-07985 Pregnancy Uterine Full Term Age of Gestation: 38 weeks and 6 days Cathely R.) PRC No.) PNA No. MAN 4 06-09025 Pregnancy Uterine Full Term Age of Gestation: 40 weeks and 5 days Maria Mylin Yungod 32 11/9/2006 10:45 AM Female Minglanilla District Hospital Normal Spontaneous Vaginal Delivery Mr. Amparado. VILLEGAS _______ Signature over printed name of Clinical Coordinator Date Signed: _____________________________ Degree: _________________________________ a.) PNA No. Deliveries Assisted No . RN. Amparado.) ANSAP No.: _____________________ Valid until: c. Amparado.: _____________________ Valid until: _______________________ (NAME OF CHIEF NURSE)____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _ _______________________ a. MERCY MILAGROS B.: 16223_______________ Valid until: 12/31/07____________ MS. APUHIN Name of Student Signature over printed name of Faculty Date Signed: ____________________ Degree: _MAN___________________ a.: ‘0307204__________ __ Valid until: March 3. RN. 2009__________________ b.) PNA No.) PNA No. Amparado. ______________________ Valid until: _______________________ . Mauro Allan P. Cebu City Accreditation Level (if any): Year Granted: First Course (if any): ____________________________________________________________________________________ School Graduated From: ________________________________ Year: Year of Admission in the Bachelor of Science in Nursing Program: Year Graduated (BSN Program): IV. Diagnosis Name of Mother Age Date of Delivery Time of Delivery Gender of Baby Name of Hospital Type of Delivery Supervised by: Name & Signature of Qualified C. Mauro Allan P. Mauro Allan P. MAN Prepared by: Supervised by: Noted by: MRS.Governor Cuenco Avenue.: ________________________ Valid until: ________________________ b. Case No. MAN 2 065173 Pregnancy Uterine Full Term Age of Gestation: 39 weeks and 3 days Lilian J.Banilad Governor Cuenco Avenue.) PRC No. Basalo 31 3/22/2007 9:50 AM Male Minglanilla District Hospital Normal Spontaneous Vaginal Delivery Mr. RN. Bedio 27 7/1/2006 7:23 AM Male Severo Verallo Memorial Hospital Normal Spontaneous Vaginal Delivery Mr.I. Mauro Allan P.) PRC No. Mauro Allan P. MAN 5 07-03435 Pregnancy Uterine Full Term Age of Gestation: 40 weeks and 5 days Jenny Rose A.: ________________________ Valid until: ________________________ c. Banilad Cebu City Page _7_ of 10 Name of Student: Name & Address of School: _ University of Cebu . RN. 2010________ b. Atienza 36 10/18/2006 10:40 AM Male Minglanilla District Hospital Normal Spontaneous Vaginal Delivery Mr. 1 279210 Pregnancy Uterine Full Term Age of Gestation: 37 weeks and 2 days Yolanda Calo 25 8/18/2005 12:03 PM Male Visayas Community Medical Center Normal Spontaneous Vaginal Delivery Mr. Amparado.: _443__________________________ Valid until: _Lifetime______________________ Concurred by: Concurred by: (NAME OF CHIEF NURSE) ___________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _ ______________________ a.

) PNA No.) PRC No._DM___________________ a.: 2764_____________________ Valid until: Lifetime__________________ c. 2011____________ b.Concurred by: Approved by: (NAME OF CHIEF NURSE)____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: _ ____________________ a. rules and regulations of the Republic of the Philippines.: ‘0075238__________________ Valid until: June 19. verified by me and to the best of my knowledge and belief is a true. correct. _______________________________________ Signature of Applicant Subscribed and sworn to before me this _______ day of ___________________________ 20 ____.) PNA No. Philippines.) PRC No. and complete statement pursuant to the provisions of pertinent laws.: 154____________________ Valid until: 2007____________________ I declare under oath that these cases had been accomplished by me in good faith. NOTARY PUBLIC Page _9_ of _10_ University of Cebu College of Nursing – Banilad Campus . _________________________________________.: ________________________ Valid until: ________________________ c.) ANSAP No. HELEN C.) ADCPN No.: ________________________ Valid until: ________________________ b. ESTRELLA _____________ Signature over printed name of Dean Date Signed: ________________________ Degree: __MN.: ______________________ Valid until: _______________________ DR.

Villanueva 24 Chong Hua Hospital Mr.I.: ______________________ Valid until: _______________________ . Case No.) PNA No. MAN 4 22327747 5/23/2006 Baby Girl Desucatan Female Janese Desucatan 23 Chong Hua Hospital Mr.: ‘0307204__________ __ ____ Valid until: March 3. Banilad Cebu City Name of Student: Name & Address of School: University of Cebu . Amparado. Amparado. 2009_________________ b. VILLEGAS_______ Signature over printed name of Clinical Coordinator Date Signed: _____________________________ Degree: _________________________________ a.) ANSAP No. Mauro Allan P. 2010_____________ b. RN.: ‘0034689______________________ Valid until: June 15. Amparado. MAN 3 03123 10/13/2005 Baby Girl Setias Female Erlinda Setias 43 Lapu-lapu District Hospital Mr.Governor Cuenco Avenue. RN.) PNA No. Mauro Allan P. RN.) PRC No. Amparado.: ______________________ Valid until: _______________________ (NAME OF CHIEF NURSE) __________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: __ _____________________ a.: ____________________ Valid until: ________________ c. RN. MAN Prepared by: Concurred by: Name of Student Concurred by: Supervised by: Noted by: MRS.: ________________________ Valid until: ________________________ c.: 16223_____________________ MS.) PRC No.) ANSAP No.) PRC No. Cebu City________________________________________________________________________________________________________________ Accreditation Level (if any): _ ________________________________________________________ Year Granted: ____________________________________________________________________________________ First Course (if any): ____________________________________________________________________________________ School Graduated From: ________________________________ Year: _______________________________ Year of Admission in the Bachelor of Science in Nursing Program: _______________________________________________________________________________________________________________________________________ Year Graduated (BSN Program): _____________________________________________________________________________________________________________________________________________________________ V.) PRC No. PILUCHI VICTORINA M. Mauro Allan P.: _443_________________________ Valid until: _Lifetime_____________________ (NAME OF CHIEF NURSE) ____________ Signature over printed name of Chief Nurse Date Signed: ________________________ Degree: ___ _____________________ a. Amparado. Mauro Allan P. Cord Dressing No . Date Performed Name of Baby Gender of Baby Name of Mother Age Name of Hospital Supervised by: Name & Signature of Qualified C. Mauro Allan P. MAN 2 275511 8/27/2005 Baby Boy Dy Male Narcisa Dy 31 Visayas Community Medical Center Mr.: ________________________ Valid until: ________________________ b.) PNA No. Banilad. RN. 1 275481 8/26/2005 Baby Boy Rosel Male May Rosel 22 Visayas Community Medical Center Mr.:_ __________ Valid until: b.Banilad Governor Cuenco Avenue. APUHIN Signature over printed name of Faculty Date Signed: ____________________ Degree: _MAN___________________ a. MERCY MILAGROS B. MAN 5 02235443 6 10/8/2006 Baby Girl Villanueva Female Mara C.) PNA No.

rules and regulations of the Republic of the Philippines.: ‘0075238__________________ Valid until: June 19. and complete statement pursuant to the provisions of pertinent laws.: 154____________________ Valid until: 2007____________________ I declare under oath that these cases had been accomplished by me in good faith. HELEN C. _________________________________________.) ADCPN No. DM ___________________ a. correct. NOTARY PUBLIC . 2008_____________ b. _______________________________________ Signature of Applicant Subscribed and sworn to before me this _______ day of ___________________________ 20 ____.: 2764_____________________ Valid until: Lifetime__________________ c.Approved by: DR. verified by me and to the best of my knowledge and belief is a true. ESTRELLA______________ Signature over printed name of Dean Date Signed: ________________________ Degree: _ MN. Philippines.) PRC No.) PNA No.