SURGICAL CIRCULATING in Jose C. Payumo Jr.

Memorial Hospital

Prepared by: Francisco D. Dador Jr. Signature of Student:

SUPERVISED BY:
Date performed and Time
Patient’s Name / Case Number PROCEDURE PERFORMED O.R Nurse on duty Clinical Instructor’s Name and
Started
Signature
November 9, 2022 Frugalidad Gwendolyn Mrs. Richelle Tolentino, RN,
LTCS RN Bautista / RN Cruz
9:57 AM 21-92-14 MAN

January 24, 2023 Jenelyn Piol Nacional Modified Radical Mastectomy

RN Angeles /RN Guevarra Mrs. Doreen Flores, RN, MAN
11:12 AM 12-01-73 Left

February 1, 2023 Lerna Paranga Vianzon

TAHBSO RN Guevarra / RN Sitjar / RN Mrs. Doreen Flores, RN, MAN
2:26 PM 22-35-55
Cerezo / RN Gerald

Noted by: Concurred by: Approved by:

Amarah E. Roxas Yolanda V. Esconde Jayvee F. Daracay

Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
OR, Head Nurse Chief Nurse Dean, College of Nursing
Date Signed: Date Signed: Date Signed:
Degree: RN, MANc Degree: RN, MAN Degree: RN, MAN
PRC No.: 0338691 PRC No.: 0259219 PRC No.: 0809989
Valid until: June 29, 2025 Valid until: September 26, 2023 Valid until: January 07, 2025
Noted by:
Amarah E. Roxas
Signature Over Printed Name
OR, Head Nurse
Date Signed:
Degree: RN, MANc
PRC No.: 0338691
Valid until: June 29, 2025
Concurred by: Approved by:
Yolanda V. Esconde Jayvee F. Daracay
Signature Over Printed Name Signature Over Printed Name
Chief Nurse Dean, College of Nursing
Date Signed: Date Signed:
Degree: RN, MAN Degree: RN, MAN
PRC No.: 0259219 PRC No.: 0809989
Valid until: September 26, 2023 Valid until: January 07, 2025