LA SALLE UNIVERSITY ODC Form 1

VALCONCHA STREET, 7200 OZAMIZ CITY, MISAMIS OCCIDENTAL, PHILIPPINES O.R. SCRUB FORM
(88) 521-0342/registrar@lsu.edu.ph/lsu.edu.ph

SURGICAL SCRUB in Mayor Hilarion A. Ramiro Sr. Medical Center, Ozamiz City, Misamis Occidental
Hospital, Municipality/City/Province

Prepared by:
Name of Student: JOBERT P. ROSILLOSA Signature of Student

PATIENT’S INITIALS SUPERVISED BY:

DATE PERFORMED AND TIME O.R. NURSE ON DUTY
PROCEDURE PERFORMED Clinical Instructor
STARTED (Name Only)
CASE NUMBER Name and Signature
PROCTOSIGMOIDOSCOPY
November 14, 2022 C. R.
HEMORRHOIDECTOMY JAMES PAUL M. MANLOZA BENJIEBER SILVA, MN
12:20 P.M 40-50-26

November 17, 2022 M. M. EXPLORATORY LAPAROTOMY,

CLYDE NOEL T. TATOY BENJIEBER SILVA, MN
12:55 P.M 40-65-54 APPENDECTOMY, LAVAGE

November 17, 2022 M. G. RECTAL CANCER STAGE 3 COLOSTOMY

CLYDE NOEL L. TATOY BENJIEBER SILVA, MN
2:50 P.M 37-95-81 OBSTRUCTION

Noted by: HARRIET C. JIMENEZ, RN, MN Approved by: ARLENE D. APAO, RN, MN, MAN
Clinical Coordinator Dean

PRC I.D No. 0622114 Valid Until: JUNE 25, 2024 PRC I.D No. 0205619 Valid Until March 20, 2024
PNA No. Valid Until PNA No. Valid Until ______________________
Date document is signed: Time: ADPCN No. 20-818__ Valid Until May 31, 2023_________
Please specify Highest Nursing Degree Earned: MN Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN
 LA SALLE UNIVERSITY
VALCONCHA STREET, 7200 OZAMIZ CITY, MISAMIS OCCIDENTAL, PHILIPPINES ODC Form 5
(88) 521-0342/registrar@lsu.edu.ph/lsu.edu.ph O.R. CIRCULATING FORM

SURGICAL CIRCULATING in Mayor Hilarion A. Ramiro Sr. Medical Center, Ozamiz City, Misamis Occidental
Hospital, Municipality/City/Province
Prepared by:
Name of Student: JOBERT P. ROSILLOSA Signature of Student

PATIENT’S INITIALS SUPERVISED BY:

DATE PERFORMED AND TIME O.R. NURSE ON DUTY
PROCEDURE PERFORMED Clinical Instructor
STARTED CASE NUMBER (Name Only)
Name and Signature

November 14, 2022 S.R LAPAROSCOPIC

JAMES PAUL M. MANLOZA BENJIEBER SILVA, MN
9:10 A.M 40-45-40 CHOLECYSTECTOMY

November 15, 2022 Y. C.

DEBRIDEMENT LEFT LEG JOHN EDWARD V. DEGAMON BENJIEBER SILVA, MN
8:55 A.M 40-64-09

November 17, 2022 C. E.

SUPERFICIAL PAROTIDECTOMY SHERRIE GRACE D. DECENA MN BENJIEBER SILVA, MN
9:31 A.M 40-71-04

Noted by: HARRIET C. JIMENEZ, RN, MN Approved by: ARLENE D. APAO, RN, MN, MAN
Clinical Coordinator Dean

PRC I.D No. 0622114 Valid Until: JUNE 25, 2024 PRC I.D No. 0205619 Valid Until March 20, 2024
PNA No. Valid Until PNA No. Valid Until ______________________
Date document is signed: Time: ADPCN No. 20-818__ Valid Until May 31, 2023_________
Please specify Highest Nursing Degree Earned: MN Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN