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  • PRC Form Salazar

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    Cheska Ann Ramos
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    1) The document appears to be from Olivarez College in Tagaytay, Cavite and contains forms for surgical scrub, surgical circulating, and immediate newborn cord care clinical experiences. 2) The forms include fields for the student's name, date and time of the operation/procedure, name and case number of the patient, the surgical procedure or newborn care performed, and the supervising nurse and instructor. 3) The forms require signatures from the student, clinical coordinator, Dean of the College of Nursing, and other approving officials.

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    PRC-FORM-SALAZAR.docx

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    1) The document appears to be from Olivarez College in Tagaytay, Cavite and contains forms for surgical scrub, surgical circulating, and immediate newborn cord care clinical experiences. 2) The forms include fields for the student's name, date and time of the operation/procedure, name and case number of the patient, the surgical procedure or newborn care performed, and the supervising nurse and instructor. 3) The forms require signatures from the student, clinical coordinator, Dean of the College of Nursing, and other approving officials.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    12 views10 pages

    PRC Form Salazar

    Uploaded by

    Cheska Ann Ramos
    1) The document appears to be from Olivarez College in Tagaytay, Cavite and contains forms for surgical scrub, surgical circulating, and immediate newborn cord care clinical experiences. 2) The forms include fields for the student's name, date and time of the operation/procedure, name and case number of the patient, the surgical procedure or newborn care performed, and the supervising nurse and instructor. 3) The forms require signatures from the student, clinical coordinator, Dean of the College of Nursing, and other approving officials.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 10

    Olivarez College – Tagaytay ODC Form 1

    College of Nursing O.R. SCRUB


    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301

    SURGICAL SCRUB in _QUALIMED__

    Prepared by:
    Supervised by:
    Date of Time Name of Patient Surgical Procedure O.R. Nurse on Duty
    No. Case # Clinical Instructor
    Operation Started (Initials only) Performed (Name and Signature)
    ( Name and Signature )
    1

    Name of Student: SALAZAR, JELLAH NICOLE D. Signature of Student: ____________________

    Noted by: Approved by:


    Clinical Coordinator

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ, RN, MAN, PhD
    (Signature Over Printed Name) (Signature Over Printed Name)
    Highest Nursing Degree Earned: BSN MAN PhD Dean Highest Nursing Degree Earned: __BSN MAN PhD_
    PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480 Valid Until 7-24-2024
    PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until 2022
    PNA No. 2022-008386 Valid Until 2022
    Olivarez College – Tagaytay ODC Form 2
    O.R.
    College of Nursing CIRCULATING
    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301

    SURGICAL CIRCULATING in SILANG SPECIALIST MEDICAL CENTER (SSMC)


    Prepared by:
    Name of Student: CORTEZ, MARYJOY B. Signature of Student:-
    _________________________
    Clinical Coordinator

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ RN, MAN, PhD
    (Signature Over Printed Name) (Signature Over Printed Name)
    Highest Nursing Degree Earned: BSN MAN PhD Highest Nursing Degree Earned: __BSN MAN PhD_
    Dean

    PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480_ Valid Until 7-24-2024
    PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until _2022_
    PNA No. 2022-008386 Valid Until 2022

    Name of Supervised by:


    Date of Time Surgical Procedure O.R. Nurse on Duty
    No. Case # Patient Clinical Instructor
    Operation Started Performed (Name and Signature)
    (Initials only) ( Name and Signature )
    1 04/13/2022 5:46 AM 22-0163 E. M. S. Evacuation of Hematoma NINA SARAH F. SIMBULAN, RN JON-JON T. MARTINEZ, RN,MAN,
    PhD
    PRC No. 0245827 Valid Until: 07-15-
    2024
    PNA No. 2022-011856 Valid Until:
    2022

    Noted by: Approved by:


    Olivarez College – Tagaytay ODC Form 3
    D.R IMMEDIATE
    College of Nursing NEWBORN
    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301

    IMMEDIATE NEWBORN CORD CARE in _QUALIMED__

    Prepared by:
    Name of Student: SALAZAR, JELLAH NICOLE D. Signature of Student:_________________________
    D.R. Nurse on duty
    Name of Immediate Newborn (Name and Signature) Supervised by:
    Date of Time
    No. Case # Patient Cord Care Performed If Midwife on Duty Clinical Instructor
    Operation Started
    (Initials only) (Signature not ( Name and Signature )
    Required)
    1

    Noted by: Approved by:


    Clinical Coordinator

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ, RN, MAN, PhD
    (Signature Over Printed Name) (Signature Over Printed Name)
    Highest Nursing Degree Earned: BSN MAN PhD Highest Nursing Degree Earned: __BSN MAN, PhD_
    Dean

    PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480_ Valid Until 7-24-2024
    PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until _2022
    PNA No. 2022-008386 Valid Until 2022
    Olivarez College – Tagaytay ODC Form 4
    D.R. ACTUAL
    College of Nursing FORM
    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301
    ACTUAL DELIVERY CARE in _QUALIMED__

    Prepared by:
    Name of Student: SALAZAR, JELLAH NICOLE D. Signature of Student:_________________________

    D.R. Nurse on duty


    Name of (Name and Signature) Supervised by:
    Date of Time Immediate Newborn
    No. Case # Patient If Midwife on Duty Clinical Instructor
    Operation Started Cord Care Performed
    (Initials only) (Signature not ( Name and Signature )
    Required)
    1

    Noted by: Approved by:


    Clinica

    Dean
    l

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ RN, MAN, PhD
    (Signature Over Printed Name) (Signature Over Printed Name)
    Co Highest Nursing Degree Earned: BSN MAN PhD Highest Nursing Degree Earned: __BSN MAN PhD_
    or PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480_ Valid Until 7-24-2024
    din PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until _2022_
    ato PNA No. 2022-008386 Valid Until 2022
    r

    Olivarez College – Tagaytay ODC Form 4


    D.R. ACTUAL
    College of Nursing FORM
    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301
    ACTUAL DELIVERY CARE in _QUALIMED__
    Prepared by:
    Name of Student: SALAZAR, JELLAH NICOLE D. Signature of Student:_________________________

    D.R. Nurse on duty


    Name of Immediate Newborn (Name and Signature) Supervised by:
    Date of Time
    No. Case # Patient Cord Care Performed If Midwife on Duty Clinical Instructor
    Operation Started
    (Initials only) (Signature not ( Name and Signature )
    Required)
    1
    Noted by: Approved by:
    Clinical Coordinator

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ, RN, MAN, PhD
    (Signature Over Printed Name) (Signature Over Printed Name)
    Highest Nursing Degree Earned: BSN MAN PhD Highest Nursing Degree Earned: __BSN MAN PhD_

    Dean
    PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480_ Valid Until 7-24-2024
    PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until _2022_
    PNA No. 2022-008386 Valid Until 2022

    Olivarez College – Tagaytay ODC Form 5


    D.R. ASSIST FORM
    College of Nursing
    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301

    ASSIST DELIVERY CARE in _QUALIMED__


    Prepared by:
    Name of Student: SALAZAR, JELLAH NICOLE D. Signature of Student:_________________________

    Noted by: Approved by:


    Clinical Coordinator

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ, RN, MAN, PhD
    (Signature Over Printed Name) (Signature Over Printed Name)
    Highest Nursing Degree Earned: BSN MAN PhD Highest Nursing Degree Earned: __BSN MAN PhD_

    Dean
    PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480_ Valid Until 7-24-2024
    PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until _2022_
    PNA No. 2022-008386 Valid Until 2022

    D.R. Nurse on duty Supervised by:


    Date of Name of (Name and Signature) Clinical Instructor
    Time
    No. Operation Case # Patient If Midwife on Duty ( Name and Signature )
    Started Procedure Performed
    (Initials only) (Signature not
    Required)

    3
    Olivarez College – Tagaytay ODC Form 2
    College of Nursing O.R.
    CIRCULATING
    E. Aguinaldo Hi-way Brgy. San Jose,
    Tagaytay City, Cavite
    Tel # (046) 860-2301

    SURGICAL CIRCULATING in _QUALIMED__

    Prepared by:
    Supervised by:
    Date of Time Name of Patient Surgical Procedure O.R. Nurse on Duty
    No. Case # Clinical Instructor
    Operation Started (Initials only) Performed (Name and Signature)
    ( Name and Signature )
    1

    Name of Student: SALAZAR, JELLAH NICOLE D. Signature of Student: ____________________

    Noted by:
    Clinical Coordinator

    RAQUEL M. PEREZ, RN, MAN, PhD JEAN RIZZA A. DELA CRUZ, RN, MAN, PhD
    Approved (Signature Over Printed Name) (Signature Over Printed Name) by:
    Highest Nursing Degree Earned: BSN MAN PhD Highest Nursing Degree Earned: __BSN MAN PhD_

    Dean
    PRC No. 0386887 Valid Until 2-21-2024 PRC No. 0220480 Valid Until 7-24-2024
    PNA No. 2022-011854 Valid Until 2022 ADPCN No. 11-113 Valid Until 2022
    PNA No. 2022-008386 Valid Until 2022

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