COLEGIO SAN AGUSTIN – BACOLOD ODC FORM 1C

CORD CARE FORM

COLLEGE OF HEALTH AND ALLIED PROFESSIONS
P.O. Box 120, B.S. Aquino Drive
Bacolod City 6100 Philippines
CSA-B Website : www.csab.edu.ph
CHED RECOGNIZED : No. 119, June 2, 1975

NURSING PROGRAM

PHILIPPINE ACCREDITING ASSOCIATION OF SCHOOLS, COLLEGES & UNIVERSITIES

(PAASCU LEVEL III ACCREDITED) valid until May 2025

ACTUAL DELIVERY in : ____________________________________________________________

Prepared by : ___________________________________
EXAMINEE

DATE PATIENT’S INITIAL ONLY IMMEDIATE NEWBORN CORD D.R. Nurse On Duty SUPERVISED BY:
PERFORMED & TIME STARTED Case Number CARE PERFORMED (Name & Signature) Clinical Instructor
(Not Applicable for Birthing/Lying in Clinics/ (If Midwife on Duty Signature Not Name & Signature
Homes) Indicate where performed e.g. Required)
D.R., Nursery, NCU or Home

Noted by : CLINICAL COORDINATOR Approved by : Dean

MARY LOU G. ABRAHAM, RN, MAN JO ANN A. FLORES, Ph.D, RN

PRC No : 0218764 Valid Until : November 17, 2024 PRC No : 0173428 Valid Until : January 20, 2023
Date Document is signed : Time : Date Document is signed : Time :
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: PhD

(STRICTLY NO DESIGNATES)