Caseload Caseslip For DR and or 1

1 2
UNIVERSITY OF PANGASINAN Name of Patient:________________________________________ Name of Patient:_______________________________________

PHINMA Education Network Address: ______________________________________________ Address: _____________________________________________
College of Nursing Age: _______ Sex: __________ Ward: ______________________ Age: _______ Sex: __________ Ward: _____________________
Case No:______________ Date: ___________________________ Case No:______________ Date: __________________________
Dagupan City
Pre- Op Diagnosis:_______________________________________ Pre- Op Diagnosis:______________________________________
______________________________________________________ ____________________________________________________
CIRCULATING CASE SLIP Post- Op Diagnosis:______________________________________ Post- Op Diagnosis:_____________________________________
_____________________________________________________ ____________________________________________________
Operation Performed:____________________________________ Operation Performed: ___________________________________
_____________________________________________________ ____________________________________________________
Name of Student Cutting Time:______________ Closing Time:_________________ Cutting Time:______________ Closing Time:________________
Surgeon: ______________________________________________ Surgeon: _____________________________________________
___________________________ Assistant: _____________________________________________ Assistant: ____________________________________________
Student Number Anesthesiologist: _______________________________________ Anesthesiologist: ______________________________________
Type of Anesthesia:_____________________________________ Type of Anesthesia:____________________________________
Medicine Used: ________________________________________ Medicine Used: _______________________________________
PROF. REBENSON F. SISON, BSN-RN, MSN Induction Time: ______________________________________ Anesthesia Started: ____________________________________
Scrub Student Nurse: ______________________________________ Scrub Student Nurse: ____________________________________
Clinical Coordinator Circulating Student Nurse: _________________________________ Circulating Student Nurse: ________________________________
_________________________ ______________________ _________________________ _____________________
PRC NO: 0769820 VALID UNTIL: September 16, 2024 Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PNA NO: M-29900 VALID UNTIL: _December 31, 2023
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________
ANSAP NO: VALID UNTIL: ________________
Agency: _____________________________________________ Agency:_____________________________________________
Name of Patient:_______________________________________ 3 Name of Patient:_______________________________________ 4 Name of Patient:_______________________________________ 5

Address: _____________________________________________ Address: _____________________________________________ Address: _____________________________________________
Age: _______ Sex: __________ Ward: _____________________ Age: _______ Sex: __________ Ward: _____________________ Age: _______ Sex: __________ Ward: _____________________
Case No:______________ Date: __________________________ Case No:______________ Date: __________________________ Case No:______________ Date: __________________________
Pre- Op Diagnosis:______________________________________ Pre- Op Diagnosis:______________________________________ Pre- Op Diagnosis:______________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Post- Op Diagnosis:_____________________________________ Post- Op Diagnosis:_____________________________________ Post- Op Diagnosis:_____________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Operation Performed: ___________________________________ Operation Performed: ___________________________________ Operation Performed: ___________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Cutting Time:______________ Closing Time:________________ Cutting Time:______________ Closing Time:________________ Cutting Time:______________ Closing Time:________________
Surgeon: _____________________________________________ Surgeon: _____________________________________________ Surgeon: _____________________________________________
Assistant: ____________________________________________ Assistant: ____________________________________________ Assistant: ____________________________________________
Anesthesiologist: ______________________________________ Anesthesiologist: ______________________________________ Anesthesiologist: ______________________________________
Type of Anesthesia:____________________________________ Type of Anesthesia:____________________________________ Type of Anesthesia:____________________________________
Medicine Used: _______________________________________ Medicine Used: _______________________________________ Medicine Used: _______________________________________
Induction Time: ____________________________________ Induction Time: ____________________________________ Induction Time: ____________________________________
Scrub Student Nurse: _____________________________________ Scrub Student Nurse: ___________________________________ Scrub Student Nurse: ___________________________________
Circulating Student Nurse: _________________________________ Circulating Student Nurse: ______________________________ Circulating Student Nurse: ________________________________
_________________________ _____________________ _________________________ ______________________ _________________________ _____________________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________
Agency:_____________________________________________ Agency:_____________________________________________ Agency:_____________________________________________
1 2
UNIVERSITY OF PANGASINAN Name of Patient:_______________________________________ Name of Patient:_______________________________________
PHINMA Education Network Address: _____________________________________________ Address: _____________________________________________
College of Nursing Age: _______ Sex: __________ Ward: _____________________ Age: _______ Sex: __________ Ward: _____________________
Case No:______________ Date: __________________________ Case No:______________ Date: __________________________
Dagupan City
Pre- Op Diagnosis:______________________________________ Pre- Op Diagnosis:______________________________________
____________________________________________________ ____________________________________________________
SCRUB CASE SLIP Post- Op Diagnosis:_____________________________________ Post- Op Diagnosis:_____________________________________
____________________________________________________ ____________________________________________________
Operation Performed: ___________________________________ Operation Performed: ___________________________________
____________________________________________________ ____________________________________________________
Name of Student Cutting Time:______________ Closing Time:________________ Cutting Time:______________ Closing Time: :________________
Surgeon: _____________________________________________ Surgeon: _____________________________________________
___________________________ Assistant: ____________________________________________ Assistant: ____________________________________________
Student Number Anesthesiologist: ______________________________________ Anesthesiologist: ______________________________________
Type of Anesthesia:____________________________________ Type of Anesthesia:____________________________________
Medicine Used: _______________________________________ Medicine Used: _______________________________________
PROF. REBENSON F. SISON, BSN-RN, MSN Induction Time: ____________________________________ Induction Time: ____________________________________
Scrub Student Nurse: _____________________________________ Scrub Student Nurse: _____________________________________
Clinical Coordinator Circulating Student Nurse: ________________________________ Circulating Student Nurse: ________________________________
_________________________ _____________________ _________________________ _____________________
PRC NO: 0769820 VALID UNTIL: September 16, 2024 Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
ANSAP NO: VALID UNTIL: ________________
Agency:_____________________________________________ Agency:_____________________________________________
Name of Patient:_______________________________________ 3 Name of Patient:_______________________________________ 4 Name of Patient:_______________________________________ 5

Address: _____________________________________________ Address: _____________________________________________ Address: _____________________________________________
Age: _______ Sex: __________ Ward: _____________________ Age: _______ Sex: __________ Ward: _____________________ Age: _______ Sex: __________ Ward: _____________________
Case No:______________ Date: __________________________ Case No:______________ Date: __________________________ Case No:______________ Date: __________________________
Pre- Op Diagnosis:______________________________________ Pre- Op Diagnosis:______________________________________ Pre- Op Diagnosis:______________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Post- Op Diagnosis:_____________________________________ Post- Op Diagnosis:_____________________________________ Post- Op Diagnosis:_____________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Operation Performed: ___________________________________ Operation Performed: ___________________________________ Operation Performed: ___________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Cutting Time:______________ Closing Time:________________ Cutting Time:______________ Closing Time:________________ Cutting Time:______________ Closing Time:________________
Surgeon: _____________________________________________ Surgeon: _____________________________________________ Surgeon: _____________________________________________
Assistant: ____________________________________________ Assistant: ____________________________________________ Assistant: ____________________________________________
Anesthesiologist: ______________________________________ Anesthesiologist: ______________________________________ Anesthesiologist: ______________________________________
Type of Anesthesia:____________________________________ Type of Anesthesia:____________________________________ Type of Anesthesia:____________________________________
Medicine Used: _______________________________________ Medicine Used: _______________________________________ Medicine Used: _______________________________________
Induction Time: ____________________________________ Induction Time: ____________________________________ Induction Time: ____________________________________
Scrub Student Nurse: _____________________________________ Scrub Student Nurse: ____________________________________ Scrub Student Nurse: ___________________________________
Circulating Student Nurse: ________________________________ Circulating Student Nurse: _______________________________ Circulating Student Nurse: ______________________________
_________________________ _____________________ _________________________ _____________________ _________________________ _____________________
Agency:________________________________________________ Agency:_________________________________________________ Agency:________________________________________________
UNIVERSITY of PANGASINAN
PHINMA EDUCATION NETWORK University Seal
COLLEGE OF NURSING
Arellano St. Dagupan City
Phone No. (075)522-5635-37; Fax No. (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Date School/Program was recognized: May 19, 1976; Number 44; Year: 1976)
(Level I PACUCOA; Year Granted: March 05, 2007)
SURGERY IN___________________________________________________________________________________________
Hospital/Home/Lying-in Clinic/Municipality/City/Province
O.R Form 1A
O.R SCRUB FORM
Prepared by: Major
Printed Name with Signature of Student:________________________________________________________________________
Date Performed Patient’s INITIAL only Supervised by:

And PROCEDURE PERFORMED O.R.NURSE ON DUTY CLINICAL INSTRUCTOR
Time Started (Name and Signature)
Case Number
Noted by: REBENSON F. SISON Approved by: MARIA TERESA R. FAJARDO______________

Clinical Coordinator College Dean
PRC I.D No. ______0769820____________ Valid Until: September 16, 2024__ PRC I.D No. 0160104_____________ Valid Until: September 09, 2025______________
Date document is signed: _______________ Time:_________________________ Date document is signed: Time: ___________________________________
Please Specify Degree Earned: RN, MSN ________________________________ Please Specify Degree Earned: RN, MAN, Ed.D _____________________________________________
COLLEGE OF NURSING
SURGERY IN__________________________________________________________________________________________
O.R Form 1B
O.R CIRCULATING FORM
Prepared by: Major

And PROCEDURE PERFORMED O.R.NURSE ON DUTY CLINICAL INSTRUCTOR
Time Started (Name and Signature)
Case Number
Noted by: REBENSON F. SISON _____ Approved by: MARIA TERESA R. FAJARDO_________
PRC I.D No. ______0769820____________ Valid Until: September 16, 2024__ PRC I.D No. 0160104_____________ Valid Until: September 09, 2025_____
Date document is signed: _______________ Time:_________________________ Date document is signed: Time: __________________________________
Please Specify Degree Earned: RN, MSN________________________________ Please Specify Degree Earned: RN, MAN, Ed.D ____________________________________
COLLEGE OF NURSING
ACTUAL DELIVERY IN____________________________________________________________________________________

D.R Form 1A
Actual Delivery
Prepared by: FORM

And PROCEDURE PERFORMED D.R NURSE/MIDWIFE ON CLINICAL INSTRUCTOR
Time Started Case Number DUTY (Name and Signature)
(Not Applicable for
Birthing/Lying-in Clinics/Homes

PRC I.D No. _____0769820_________ Valid Until: September 16, 2024_ PRC I.D No. 0160104_____________ Valid Until: September 09, 2025______________
Date document is signed: ________________ Time:__________________ Date document is signed: Time: ___________________________________
Please Specify Degree Earned: RN, MSN__________________________ Please Specify Degree Earned: RN, MAN, Ed.D _____________________________________________
COLLEGE OF NURSING
ASSISTED DELIVERY IN_________________________________________________________________________________

D.R Form 1B
ASSISTED DELIVERY
Prepared by: FORM

And PROCEDURE PERFORMED D.R NURSE/MIDWIFE ON CLINICAL INSTRUCTOR
Time Started Case Number DUTY (Name and Signature)
(Not Applicable for

PRC I.D No. 0769820___________ Valid Until: September 16, 2024 PRC I.D No. 0160104_____________ Valid Until: September 09, 2025______________
Date document is signed: ___________ Time: ______________________ Date document is signed: Time: __________________________________
Please Specify Degree Earned: RN, MSN__________________________ Please Specify Degree Earned: RN, MAN, Ed.D _____________________________________________
COLLEGE OF NURSING
ESSENTIAL NEWBORN CARE IN_________________________________________________________________________

E.N.C Form
ESSENTIAL NEWBORN
Prepared by: CARE FORM
Date Performed Patient’s INITIAL only Essential Newborn Cord Care Supervised by:
And PERFORMED D.R NURSE/MIDWIFE ON CLINICAL INSTRUCTOR
Time Started Case Number Indicate where performed e.g. D.R., Nursery, DUTY (Name and Signature)
(Not Applicable for N.I.C.U., or Home

PRC I.D No. 0769820 Valid Until: September 16, 2024__ PRC I.D No. 0160104_____________ Valid Until: September 09, 2025________________
Date document is signed: ____________ Time: ______________________ Date document is signed: Time: _____________________________________
Please Specify Degree Earned: RN, MSN___________________________ Please Specify Degree Earned: RN, MAN, Ed.D ________________________________________________
FOR CASE SLIP/CASELOAD PURPOSES
COLLEGE DEAN: MARIA TERESA R. FAJARDO
PRC NO. 0160104 VALIDITY: SEPTEMBER 09, 2025
CLINICAL COORDINATOR: REBENSON F. SISON
PRC NO: 0108608 VALIDITY: SEPTEMBER 16, 2024
PNA NO.: VALIDITY:

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UNIVERSITY OF PANGASINAN Name of Patient: Name of Patient:
PHINMA Education Network ____________________________________________________ ____________________________________________________
College of Nursing Address: _____________________________________________ Address: ____________________________________________
Dagupan City Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________
Gravida: ______________ Para: __________________________ Gravida: ______________ Para: _________________________
ACTUAL CASE SLIP Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Time of Delivery: _____________________________________ Time of Delivery: _____________________________________
Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Name of Student Diagnosis: ___________________________________________ Diagnosis: __________________________________________
____________________________________________________ ____________________________________________________
___________________________ ____________________________________________________ ____________________________________________________
Student Number Obstetrician: _________________________________________ Obstetrician: _________________________________________
_________________________ _____________________ _________________________ _____________________

PROF. REBENSON F. SISON, BSN-RN, MSN Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
Clinical Coordinator
PRC NO: 0769820 VALID UNTIL: September 16, 2024
PNA NO: M-29900 VALID UNTIL: _December 31, 2023 Agency: Agency:
ANSAP NO: VALID UNTIL: ________________ ____________________________________________________ ____________________________________________________
Name of Patient: 3 Name of Patient: 4 Name of Patient: 5

____________________________________________________ ____________________________________________________ ____________________________________________________
Address: ____________________________________________ Address: _____________________________________________ Address: ____________________________________________
Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________
Gravida: ______________ Para: _________________________ Gravida: ______________ Para: __________________________ Gravida: ______________ Para: _________________________
Date of Delivery: _____________________________________ Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: ______________________________________ Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Time of Delivery: _____________________________________ Time of Delivery: _____________________________________ Time of Delivery: _____________________________________
Type of Delivery: _____________________________________ Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Diagnosis: __________________________________________ Diagnosis: ___________________________________________ Diagnosis: __________________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Obstetrician: _________________________________________ Obstetrician: _________________________________________ Obstetrician: _________________________________________
_________________________ _____________________ _________________________ _____________________ _________________________ _____________________

Agency: Agency: Agency:

____________________________________________________ ____________________________________________________ ____________________________________________________
1 2
UNIVERSITY OF PANGASINAN Name of Patient: Name of Patient:
College of Nursing Address: _____________________________________________ Address: ____________________________________________
Dagupan City Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________
Gravida: ______________ Para: __________________________ Gravida: ______________ Para: _________________________
ASSISTED CASE SLIP Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Name of Student Diagnosis: ___________________________________________ Diagnosis: __________________________________________
____________________________________________________ ____________________________________________________
___________________________ ____________________________________________________ ____________________________________________________
Student Number Obstetrician: _________________________________________ Obstetrician: _________________________________________
_________________________ _____________________ _________________________ _____________________

PROF. REBENSON F. SISON, BSN-RN, MSN Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
Clinical Coordinator
PNA NO: M-29900 VALID UNTIL: _December 31, 2023 Agency: Agency:
Name of Patient: 3 Name of Patient: 4 Name of Patient: 5

____________________________________________________ ____________________________________________________ ____________________________________________________
Address: ____________________________________________ Address: _____________________________________________ Address: ____________________________________________
Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________
Gravida: ______________ Para: _________________________ Gravida: ______________ Para: __________________________ Gravida: ______________ Para: _________________________
Gender of Baby: ______________________________________ Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Diagnosis: __________________________________________ Diagnosis: ___________________________________________ Diagnosis: __________________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Obstetrician: _________________________________________ Obstetrician: _________________________________________ Obstetrician: _________________________________________
_________________________ _____________________ _________________________ _____________________ _________________________ _____________________


____________________________________________________ ____________________________________________________ ____________________________________________________
1 2
UNIVERSITY OF PANGASINAN Name of Baby: Name of Baby:
College of Nursing Case No.: ___________________________ Case No.: _______________________
Dagupan City Name of Mother: Name of Mother:
____________________________________________________ ____________________________________________________
ESSENTIAL NEWBORN CARE CASE SLIP Address: ____________________________________________ Address: ____________________________________________
Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Sex of Baby: _______________________________________ Sex of Baby: ______________________________________
Name of Student Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Pediatrician: _________________________________________ Pediatrician: _________________________________________
___________________________
Student Number _________________________ _____________________ _________________________ _____________________
Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PROF. REBENSON F. SISON, BSN-RN, MSN _________________________ _____________________ _________________________ _____________________

Clinical Coordinator PRC No. PRC No. PRC No. PRC No.

Agency: Agency:
Name of Baby: 3 Name of Baby: 4 Name of Baby: 5

____________________________________________________ ____________________________________________________ ____________________________________________________
Case No.: ______________________ Case No.: ______________________ Case No.: ________________________
Name of Mother: Name of Mother: Name of Mother:
____________________________________________________ ____________________________________________________ ____________________________________________________
Address: ____________________________________________ Address: ____________________________________________ Address: ____________________________________________
Sex of Baby: ______________________________________ Sex of Baby: _______________________________________ Sex of Baby: ______________________________________
Pediatrician: _________________________________________ Pediatrician: _________________________________________ Pediatrician: _________________________________________
_________________________ _____________________ _________________________ _____________________ _________________________ _____________________

_________________________ _____________________ _________________________ _____________________ _________________________ _____________________
PRC No. PRC No. PRC No. PRC No. PRC No. PRC No.

____________________________________________________ ____________________________________________________ ____________________________________________________

Caseload Caseslip For DR and or 1

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Caseload Caseslip For DR and or 1

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UNIVERSITY OF PANGASINAN Name of Patient:________________________________________ Name of Patient:_______________________________________

Name of Patient:_______________________________________ 3 Name of Patient:_______________________________________ 4 Name of Patient:_______________________________________ 5

Name of Patient:_______________________________________ 3 Name of Patient:_______________________________________ 4 Name of Patient:_______________________________________ 5

Date Performed Patient’s INITIAL only Supervised by:

Noted by: REBENSON F. SISON Approved by: MARIA TERESA R. FAJARDO______________

Date Performed Patient’s INITIAL only Supervised by:

ACTUAL DELIVERY IN____________________________________________________________________________________

Date Performed Patient’s INITIAL only Supervised by:

Noted by: REBENSON F. SISON Approved by: MARIA TERESA R. FAJARDO______________

ASSISTED DELIVERY IN_________________________________________________________________________________

Date Performed Patient’s INITIAL only Supervised by:

Noted by: REBENSON F. SISON Approved by: MARIA TERESA R. FAJARDO______________

ESSENTIAL NEWBORN CARE IN_________________________________________________________________________

Noted by: REBENSON F. SISON Approved by: MARIA TERESA R. FAJARDO______________

COLLEGE DEAN: MARIA TERESA R. FAJARDO

PRC NO. 0160104 VALIDITY: SEPTEMBER 09, 2025

CLINICAL COORDINATOR: REBENSON F. SISON

PRC NO: 0108608 VALIDITY: SEPTEMBER 16, 2024

PNA NO.: VALIDITY:

_________________________ _____________________ _________________________ _____________________

Name of Patient: 3 Name of Patient: 4 Name of Patient: 5

_________________________ _____________________ _________________________ _____________________ _________________________ _____________________

Agency: Agency: Agency:

_________________________ _____________________ _________________________ _____________________

Name of Patient: 3 Name of Patient: 4 Name of Patient: 5

_________________________ _____________________ _________________________ _____________________ _________________________ _____________________

Agency: Agency: Agency:

PROF. REBENSON F. SISON, BSN-RN, MSN _________________________ _____________________ _________________________ _____________________

PRC NO: 0769820 VALID UNTIL: September 16, 2024

Name of Baby: 3 Name of Baby: 4 Name of Baby: 5

_________________________ _____________________ _________________________ _____________________ _________________________ _____________________

Agency: Agency: Agency:

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UNIVERSITY OF PANGASINAN Name of Patient:__ Name of Patient:_

Name of Patient:___________________ 3 Name of Patient:_ 4 Name of Patient:_____________________ 5

Name of Patient:___________________ 3 Name of Patient:_ 4 Name of Patient:_____________________ 5

_______________ _ _ _______

_______________ _ _____ _ _ _______

_______________ _ _ _______

_______________ _ _____ _ _ _______

PROF. REBENSON F. SISON, BSN-RN, MSN _______________ _ _ _______

_______________ _ _____ _ _ _______