NOTRE DAME UNIVERSITY

COLLEGE OF HEALTH SCIENCES
COTABATO CITY

CORD DRESS
Case Number:_______________________ Date Delivered:____________________ Time
Delivered:_________________
Name of Baby:_______________________________________________________Gender of
Baby:__________________
Name of
Mother:____________________________________________________________________________________
(First name)

(Middle name)

(Last name)

Weight:_______________________________
Length:________________________________________
Head Circumference:______________ Chest Circumference:______________ Abdominal
Circumference:_____________
Temperature:___________________________ Type of
Delivery:______________________________________________
Pediatrician on Duty:_________________________________ Obstetrician on
duty:______________________________
Nurse on Duty:______________________________________ Midwife on
duty:_________________________________
Handled by
(student):________________________________________________________________________________
Assisted by
(student):________________________________________________________________________________
Cord Dressed by
(student):____________________________________________________________________________
Name of
Institution:_________________________________________________________________________________

_________________________________
_________________________________
Signature over Printed Name
over Printed Name
Clinical Instructor
PRC License No._____________
No._____________

Signature
OR Nurse
PRC License

_____________ NOTRE DAME UNIVERSITY PRC License ._____________ No.NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY CORD DRESS Case Number:_______________________ Date Delivered:____________________ Time Delivered:_________________ Name of Baby:_______________________________________________________Gender of Baby:__________________ Name of Mother:____________________________________________________________________________________ (First name) (Middle name) (Last name) Weight:_______________________________ Length:________________________________________ Head Circumference:______________ Chest Circumference:______________ Abdominal Circumference:_____________ Temperature:___________________________ Type of Delivery:______________________________________________ Pediatrician on Duty:_________________________________ Obstetrician on duty:______________________________ Nurse on Duty:______________________________________ Midwife on duty:_________________________________ Handled by (student):________________________________________________________________________________ Assisted by (student):________________________________________________________________________________ Cord Dressed by (student):____________________________________________________________________________ Name of Institution:_________________________________________________________________________________ ___________________________________ _________________________________ Signature over Printed Name over Printed Name Clinical Instructor Signature OR Nurse PRC License No.

_____________ NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES PRC License on ._____________ No.COLLEGE OF HEALTH SCIENCES COTABATO CITY HANDLE Case Number:________________________ Patient’s name:_______________________________________________________________________ Age:__________ (First name) (Middle name) Gravida:_________________ Living:_________________ Para:________________ Date of Delivery:___________________ Newborn:___________ Time of (Last name) Abortion:____________________ Delivery:_______________________ Gender of Type of Delivery:_______________________________________________________________________________ Final diagnosis:_________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Obstetrician on Duty: by:_________________________________ _____________________________________ Nurse on duty:____________________________________________ duty:____________________________ Handled Midwife Handled by (student):________________________________________________________________________________ Assisted by (student):________________________________________________________________________________ Cord Dressed by (student):____________________________________________________________________________ Name of Institution:_________________________________________________________________________________ _________________________________ _________________________________ Signature over Printed Name over Printed Name Clinical Instructor Signature OR Nurse PRC License No.

_____________ No._____________ PRC License NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY .COTABATO CITY HANDLE Case Number:________________________ Patient’s Age:__________ name:_______________________________________________________________________ (First name) (Middle name) Gravida:_________________ Living:_________________ Para:__________________ Date of Delivery:___________________ Newborn:_____________ Time of (Last name) Abortion:_________________ Delivery:__________________ Gender of Type of Delivery:_______________________________________________________________________________ Final diagnosis:_________________________________________________________________________________ __________________________________________________________________________________________________ _______________________________________________________________________________________________ Obstetrician on Duty: by:______________________________ ____________________________________ Nurse on duty:_______________________________________ duty:____________________________ Handled Midwife on Handled (student):________________________________________________________________________________ by Assisted (student):________________________________________________________________________________ by Cord Dressed (student):____________________________________________________________________________ by Name Institution:_________________________________________________________________________________ of ___________________________________ _________________________________ Signature over Printed Name over Printed Name Signature Clinical Instructor OR Nurse PRC License No.

_____________ No.ASSIST Case Number:________________________ Patient’s name:_______________________________________________________________________ Age:__________ (First name) (Middle name) Gravida:_________________ Living:____________________ Para:________________ Date of Delivery:___________________ Newborn:_____________ Time of (Last name) Abortion:_________________ Delivery:__________________ Gender of Type of Delivery:_______________________________________________________________________________ Final diagnosis:_________________________________________________________________________________ __________________________________________________________________________________________________ _______________________________________________________________________________________________ Obstetrician on Duty: by:________________________________ __________________________________ Nurse on duty:_______________________________________ duty:____________________________ Handled Midwife Handled by (student):________________________________________________________________________________ Assisted by (student):________________________________________________________________________________ Cord Dressed by (student):____________________________________________________________________________ Name of Institution:_________________________________________________________________________________ _________________________________ _________________________________ Signature over Printed Name over Printed Name Signature Clinical Instructor OR Nurse PRC License No._____________ PRC License NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY on .

_____________ Signature OR Nurse PRC License .ASSIST Case Number:________________________ Patient’s Age:__________ name:_______________________________________________________________________ (First name) Gravida:_________________ Living:_________________ (Middle name) Para:________________ Date of Delivery:___________________ Newborn:_____________ Time of (Last name) Abortion:___________________ Delivery:__________________ Gender of Type of Delivery:_______________________________________________________________________________ Final diagnosis:_________________________________________________________________________________ __________________________________________________________________________________________________ _______________________________________________________________________________________________ Obstetrician on Duty: by:________________________________ __________________________________ Nurse on duty:_______________________________________ duty:____________________________ Handled Midwife on Handled (student):________________________________________________________________________________ by Assisted (student):________________________________________________________________________________ by Cord Dressed (student):____________________________________________________________________________ by Name Institution:_________________________________________________________________________________ of ____________________________________ _________________________________ Signature over Printed Name over Printed Name Clinical Instructor PRC License No._____________ No.

NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY MINOR Case Number:________________________ Date:_________________________________ Operation Started:____________________ Ended:_______________________ Operation Patient’s name:__________________________________________________________________Sex:______ Age:______ (First name) (Middle name) (Last name) Address:_________________________________________________________________________________________ __ Operation Done:____________________________________________________________________________________ Post-operative Diagnosis: _____________________________________________________________________________ _______________________________________________________________________________________________________________________ _ Surgeon: ______________________________________ _ Assistant Surgeon: ___________________________________ Anesthesiologist:_________________________________ Type of Anesthesia:___________________________________ OR Scrub Nurse:_____________________________________________________________________________________ Student Scrub Nurse:_________________________________________________________________________________ Student Circulating Nurse:_____________________________________________________________________________ Name of Institution:__________________________________________________________________________________ _________________________________ _________________________________ Signature over Printed Name over Printed Name Clinical Instructor PRC License No._____________ Signature OR Nurse PRC License ._____________ No.

NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY MINOR Case Number:________________________ Date:_________________________________ Operation Started:____________________ Ended:_______________________ Operation Patient’s name:__________________________________________________________________Sex:______ Age:______ (First name) (Middle name) (Last name) Address:_________________________________________________________________________________________ __ Operation Done:____________________________________________________________________________________ Post-operative Diagnosis: _____________________________________________________________________________ _______________________________________________________________________________________________________________________ _ Surgeon: ______________________________________ _ Assistant Surgeon: ___________________________________ Anesthesiologist:_________________________________ Type of Anesthesia:___________________________________ OR Scrub Nurse:_____________________________________________________________________________________ Student Scrub Nurse:_________________________________________________________________________________ Student Circulating Nurse:_____________________________________________________________________________ Name of Institution:__________________________________________________________________________________ ________________________________ ______________________________ __ .

_____________ PRC License NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY MAJOR Case Number:________________________ Date:_________________________________ Operation Started:____________________ Ended:_______________________ Operation Patient’s name:__________________________________________________________________Sex:______ Age:______ (First name) (Middle name) (Last name) Address:_________________________________________________________________________________________ __ Operation Done:____________________________________________________________________________________ Post-operative Diagnosis: _____________________________________________________________________________ _______________________________________________________________________________________________________________________ _ Surgeon: ______________________________________ _ Assistant Surgeon: ___________________________________ Anesthesiologist:_________________________________ Type of Anesthesia:___________________________________ OR Scrub Nurse:_____________________________________________________________________________________ Student Scrub Nurse:_________________________________________________________________________________ Student Circulating Nurse:_____________________________________________________________________________ Name of Institution:__________________________________________________________________________________ ._____________ No.Signature over Printed Name over Printed Name Signature Clinical Instructor OR Nurse PRC License No.

_________________________________ _________________________________ Signature over Printed Name over Printed Name Signature Clinical Instructor OR Nurse PRC License No._____________ No._____________ PRC License NOTRE DAME UNIVERSITY COLLEGE OF HEALTH SCIENCES COTABATO CITY MAJOR Case Number:________________________ Date:_________________________________ Operation Started:____________________ Ended:_______________________ Operation Patient’s name:__________________________________________________________________Sex:______ Age:______ (First name) (Middle name) (Last name) Address:_________________________________________________________________________________________ __ Operation Done:____________________________________________________________________________________ Post-operative Diagnosis: _____________________________________________________________________________ _______________________________________________________________________________________________________________________ _ Surgeon: ______________________________________ _ Assistant Surgeon: ___________________________________ Anesthesiologist:_________________________________ Type of Anesthesia:___________________________________ OR Scrub Nurse:_____________________________________________________________________________________ Student Scrub Nurse:_________________________________________________________________________________ Student Circulating Nurse:_____________________________________________________________________________ .

Name of Institution:__________________________________________________________________________________ ________________________________ ______________________________ __ Signature over Printed Name over Printed Name Signature Clinical Instructor PRC License No._____________ No._____________ OR Nurse PRC License .