Name of School: UNIVERSITY OF ST.

LA SALLE
Address: La Salle Avenue, Bacolod City 6100

Name of Student:MAGNO, MARIAH PATRICIA PAULEEN CONCEPCION CADUHADA First Course (If any) : NA Year: NA
Date School/Program was Recognized: June 14, 1983 School Graduated From: NA
Accreditation Level: NA Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010

I. MAJOR SCRUBS
Date of Type of
No. Time Started Time Ended Case No. Name of Patient Operation Performed Name of Surgeo
Operation Anesthesia

1 7:30 AM 9:15 AM 01-15-09 01093478 Gaudencio, Romulo Appendectomy SAB Dr. George Parre

Prepared by: EXAMINEE Supervised by: Noted by: CLINICAL COORDINATOR Approved by: DEAN

Mariah Patricia Pauleen Concepcion C. Magno Jean E. Javier, RN, MN Josephine L. de la Serna, RN, MN
CTC Number : Date Signed : Date Signed : Date Signed :
Date : Degree : Degree RN,
: MN Degree RN,
: MN
Place : a) PRC No : a) PRC No :0087213 a) PRC No :0037515
Valid Until : Valid Until October 6, 2009 Valid Until June 3, 2011
b) PNA No : b) PNA No 012953
: b) PNA No 10408
:
Valid Until : Valid Until December 2009 Valid Until Lifetime
 SPECIFIED FORMS & SCRUBS
As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008

Name of Surgeon Name of Hospital

Corazon Locsin Montelibano

Dr. George Parreňo
Memorial Regional Hospital

Concurred by: CHIEF NURSE

Date Signed :
Degree :
a) PRC No :
Valid Until
b) PNA No :
Valid Until
 University Of St. La Salle D. R. Form
College of Nursing ACTUAL DELIVERY FORM

La Salle Avenue, Bacolod City 6100

Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing@usls.edu.ph / www.usls.edu.ph
Granted PAASCU Accreditation Level 2 (November 2016 to November 2021)

ACTUAL DELIVERY in __________________________________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:

(Printed Name and Signature of Student)

Supervised By (Clinical Instructor)

Patient's INITIAL (only) DR Nurse On Duty
Date Performed
(Name and Signature)
and PROCEDURE PERFORMED
Case Number (If Midwife on Duty, Name and Signature
Time Started
Signature Not Required)

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

Noted by: Ivy G. Edemni RN MN Approved by: Toni-An B. Lachica RN MN PhD

Clinical Coordinator Dean
PRC ID No.: 0256609 Valid Until: 10-21-24 PRC ID No.: 0483954 Valid Until: 03-02-23
Date document is signed: Time: Date document is signed: Time:
Highest Nursing Degree Earned: Master in Nursing Highest Nursing Degree Earned: Doctor of Philosophy in Nursing
 University Of St. La Salle D. R. Form
College of Nursing ASSISTED DELIVERY FORM

La Salle Avenue, Bacolod City 6100

Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing@usls.edu.ph / www.usls.edu.ph
Granted PAASCU Accreditation Level 2 (November 2016 to November 2021)

ASSISTED DELIVERY in __________________________________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:

(Printed Name and Signature of Student)

Supervised By (Clinical Instructor)

Patient's INITIAL (only) DR Nurse On Duty
Date Performed
(Name and Signature)
and PROCEDURE PERFORMED
Case Number (If Midwife on Duty, Name and Signature
Time Started
Signature Not Required)

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

Noted by: Ivy G. Edemni RN MN Approved by: Toni-An B. Lachica RN MN PhD

Clinical Coordinator Dean
PRC ID No.: 0256609 Valid Until: 10-21-24 PRC ID No.: 0483954 Valid Until: 03-02-23
Date document is signed: Time: Date document is signed: Time:
Highest Nursing Degree Earned: Master in Nursing Highest Nursing Degree Earned: Doctor of Philosophy in Nursing
 University Of St. La Salle ICNB Form
IMMEDIATE CARE OF T
College of Nursing NEWBORN FORM
La Salle Avenue, Bacolod City 6100
Tel. #: (034) 434-4010 / Fax #: (034) 434-0415 / nursing@usls.edu.ph / www.usls.edu.ph
Granted PAASCU Accreditation Level 2 (November 2016 to November 2021)

IMMEDIATE NEWBORN CORD CARE in _____________________________________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:

(Printed Name and Signature of Student)

Patient's INITIAL (only) Immediate Newborn Cord Care DR/Nursery Nurse On Duty
Date Performed Supervised By
and PERFORMED (Name and Signature)
Instructor) N
Case Number Indicate where performed e.g. D.R., (If Midwife on
Time Started Nursery, NICU, or Home Duty, Signature Not Required) Signature

Noted by: Ivy G. Edemni RN MN Approved by: Toni-An B. Lachica RN MN PhD

Clinical Coordinator Dean
PRC ID No.: 0256609 Valid Until: 10-21-24 PRC ID No.: 0483954 Valid Until: 03-02-23
Date document is signed: Time: Date document is signed: Time:
Highest Nursing Degree Earned: Master in Nursing Highest Nursing Degree Earned: Doctor of Philosophy in Nurs
 ICNB Form
IMMEDIATE CARE OF THE
NEWBORN FORM

___________________________________________________________________

Supervised By (Clinical
Instructor) Name and
Signature

Toni-An B. Lachica RN MN PhD

03-02-23

Doctor of Philosophy in Nursing