ODC Form 2A

PHINMA - CAGAYAN DE ORO COLLEGE O.R. SCRUB FORM

Max Suniel St., Cagayan de Oro City
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph

SURGICAL SCRUB in POLYMEDIC MEDICAL PLAZA, CAGAYAN DE ORO CITY

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

Prepared by:
Name and Signature of the Student: JEMUEL B. FABORES JR.

Date Performed Patient’s INITIAL (only) SUPERVISED BY

SURGICAL PROCEDURE O. R. Nurse On duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number (Name and Signature)

January 19, 2023 LPV 714 Cysto Uteroscopy, Ureteroscopy,

6:25 PM Intracorporeal CABARING, RN RICHELLE, UBALDE RN.

February 2, 2023 JE 2066 Mesh, Hernioplasty, Right With

Omentectomy JAN CHESTER, OBLINA, RN RICHELLE, UBALDE RN.

Noted by: LINCOLN T. SUMAYLO Approved by: ROSITA P. GUTIERREZ

(Print Name & Signature) (Print Name & Signature)
Clinical Coordinator, PRC I.D. No.: 0915340 Valid Until: May 24, 2025 Dean, PRC I.D. No.: 0173650 Valid Until: January 30, 2025
Date Document is signed: __________________ Time: _________________ Date Document is signed: ____________ Time: __________________
Please specify Highest Nursing Degree Earned: Registered Nurse Please specify Highest Nursing Degree Earned: Masters in Nursing
 PHINMA - CAGAYAN DE ORO COLLEGE ODC Form 2B
Max Suniel St., Cagayan de Oro City O.R. CIRCULATING
PHONE NUMBER (088) 858-1750/S, Fax Number (088) 858-7949/S, Web-Site: www.coc.phinma.edu.ph FORM

SURGICAL SCRUB in POLYMEDIC MEDICAL PLAZA, CAGAYAN DE ORO CITY

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

Prepared by:
Name and Signature of the Student: JEMUEL. B FABORES JR.

Date Performed Patient’s INITIAL (only) SUPERVISED BY

SURGICAL PROCEDURE O. R. Nurse On duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number (Name and Signature)

February 16, 2023 Excition Of Malignant Lesion, Face

3:37 PM AB 2309 Adjacent Tissue Transfer Upper Lip,
Right FRANCES, ULAPE, RN RICHELLE, UBALDE RN.

Noted by: LINCOLN T. SUMAYLO Approved by: ROSITA P. GUTIERREZ

(Print Name & Signature) (Print Name & Signature)
Clinical Coordinator, PRC I.D. No.: 0915340 Valid Until: May 24, 2025 Dean, PRC I.D. No.: 0173650 Valid Until: January 30, 2025
Date Document is signed: __________________ Time: _________________ Date Document is signed: ____________ Time: __________________
Please specify Highest Nursing Degree Earned: Registered Nurse Please specify Highest Nursing Degree Earned: Masters in Nursing