UNIVERSITY OF SAN AGUSTIN ODC Form 2B

GENERAL LUNA STREET, ILOILO CITY O.R. CIRCULATING

Tel. No.: (033)337-48-41 to 44 Local 259, Fax No.: (033)337-44-03, E-mail Address: cn@usa.edu.ph, Web-Site: www.usa.edu.ph FORM
SURGICAL SCRUB in Dr. Catalino Gallego Nava Provincial Hospital, Jordan, Guimaras
Hospital, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student: _JOHN ROBERT C. CORCINO_

Date Performed Patient’s INITIALS (only) O.R. Nurse on Duty SUPERVISED BY

and Case Number SURGICAL PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Name and Signature

August 10,2022 D.A.O.

PRIMARY LOW TRANSVERSE CESAREAN SECTION IAN H. SERMONIA, RN CARLANE P. TORRES, PhD, RN
1:30 PM B22-0382

Noted: Dr. Carlane P. Torres, R.N.____________________________________________
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0317254 Valid Until: March 4, 2025__________
Date document is signed:_________________ Time:__________________________
Please Specify Highest Nursing Degree Earned:___ PhD__________________________
Approved: Dr. Louie P. Hijalda, R.N.__________________________________________
(Print Name and Signature)
Dean, PRC I.D. No. 0188653_______________ Valid Until May 9, 2026 ________ _
Date document is signed:_________________ Time:____________________________
Please Specify Highest Nursing Degree Earned: __PhD _________________________