Republic of the Philippines

LAGUNA STATE POLYTECHNIC UNIVERSITY ODC Form 1A

SANTA CRUZ MAINCAMPUS O.R. CIRCU FORM
Sta. Cruz, Laguna
Tel. No. (049) 810-4110
Government Recognition (CHED) No. 048-July 5, 2010, Series 2010

MINOR CASES in Laguna Provincial Hospital, Sta. Cruz, Laguna

Prepared by:
Printed Name and Signature of Student:

Date Performed Patient’s INITIALS Only SUPERVISED BY

PROCEDURE D.R. Nurse on Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started (Name and Signature)
A.V.
12/21/13 @10:30am Cesarean Section Gemma B. Iporac Victoria C. Mag-Iba
01603
L.F.
8/8/13 @ 7:00am LTCS Josie Cande Victoria C. Mag-Iba
102258

Noted by:MYRANIE L. SY, M.A.N. Approved by:MAY M. VERIDIANO, Ph.D.

(Printed Name and Signature) (Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0243620Valid Until: May 20, 2015 Dean, PRC I.D. No. 0314302 Valid Until: October 27, 2014
Date Document is signed: _________________ ______________Time:_ _ ________ Date Document is signed: _________________ ____Time:_________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: Ph.D.