MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
AMAI PAKPAK MEDICAL CENTER, MARAWI CITY, LANAO DEL SUR
Hospital, Municipality/City/Province
ODC Form 2B
Prepared by: ADZAR, ALYEAH C.. O.R. MINOR
Printed Name and Signature of Student: ADZAR, ALYEAH C.. FORM
Date Performed Patient’s INITIALS SUPERVISED BY
SURGICAL PROCEDURE O.R. Nurse on Duty
and (only) Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

HASSAN BJ T. MARABONG, RN RAQUEL D. MACARAMBON, RN, MSN

December 17, 2019 S. U. J.
Excision PRC ID No: 0804101 PRC ID No: 0270747
1:33 PM 1242-71
Valid Until: October 10, 2022 Valid Until: July 2022

HASSAN BJ T. MARABONG, RN NAMERA T. DATUMANONG, RN

January 20, 2020 C. A.
Excision PRC ID No: 0804101 PRC ID No: 0854927
1:00 PM 1031-40
Valid Until: October 10, 2022 Valid Until: October 30, 2021

WANISAH D. CALANDADA, RN NAMERA T. DATUMANONG, RN

January 23, 2020 H. A.
Wound Suturing PRC ID No: 0845684 PRC ID No: 0854927
2:35 PM 1291-59
Valid Until: February 18, 2024 Valid Until: October 30, 2021

Noted by: Approved by:

RAQUEL D. MACARAMBON, RN, MSN NAIMA D. MALA, RN, MN, MAN, Ph.D
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0270747 Valid Until: July 2022 Dean, PRC I.D. No.: 0348709 Valid Until: September 3, 2021
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Science in Nursing Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
 MINDANAO STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
MARAWI CITY
www.msumain.edu.ph
AMAI PAKPAK MEDICAL CENTER, MARAWI CITY, LANAO DEL SUR
Hospital/Home/Lying-in, Municipality/City/Province
ODC Form 1C
Prepared by: ADZAR, ALYEAH C. CORD CARE
Printed Name and Signature of Student: ADZAR, ALYEAH C. FORM
Patient’s Immediate Newborn Cord Care D.R. Nurse on Duty
Date Performed SUPERVISED BY
INITIALS (only) Performed (Name and Signature)
and Clinical Instructor
(Indicate where preformed e.g. DR, (If Midwife on Duty, Signature Not
Time Started Case Number Name and Signature
Nursery, NICU, or Home) Required)
DR
HC- 35 cm
AMALIAH M. GAMPONG, RN SHIRIKIT I. CASIM, RN, RM, LPT, MAN
January 21, 2018 B. B. G. CC- 24 cm
PRC ID No: 0877096 PRC ID No: 0470647
11:15 AM 2018-00-18-23 AC- 30 cm
Valid Until: Valid Until: September 12, 2023
WT- 3.6 kg
HT- 53 cm
DR
HC- 32 cm
RASHMIA A. ABBAS, RN, MAN SHIRIKIT I. CASIM, RN, RM, LPT, MAN
February 18, 2018 B.G. S. CC- 27 cm
PRC ID No: 0132594 PRC ID No: 0470647
1:48 PM 2018-00-29-00 AC- 30 cm
Valid Until: January 1, 2024 Valid Until: September 12, 2023
WT- 2.9 kg
HT- 50 cm
DR
HC- 38 cm
RASHMIA A. ABBAS, RN, MAN ANNIE M. MERO, RN, RM, MN
February 11, 2018 B. G. S. CC- 25 cm
PRC ID No: 0132594 PRC ID No:
11:33 AM 2018-00-29-09 AC- 31 cm
Valid Until: January 1, 2024 Valid Until:
WT- 3.1 kg
HT- 55 cm

Noted by: Approved by:

RAQUEL D. MACARAMBON, RN, MSN NAIMA D. MALA, RN, MN, MAN, Ph.D
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0270747 Valid Until: July 2022 Dean, PRC I.D. No.: 0348709 Valid Until: September 3, 2021
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master of Science in Nursing Please specify Highest Nursing Degree Earned: Master of Arts in Nursing