You are on page 1of 5

ODC Form 1A

ACTUAL DELIVERY
FORM

Our Lady of Fatima University


Esperanza St., Hilltop Mansion, Lagro, Quezon City
ACTUAL DELIVERY in
_____________________________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student______________________________________________________________________________________________________

Date Performed
And
Time Started

Patients INITIAL Only


______________________
Case Number

D.R. Nurse On Duty


(Name and Signature)
(If Midwife on Duty,
Signature not
required)

PROCEDURE
PERFORMED

(not applicable for


Birthing/Lying-In
Clinics/Homes)

Noted by:
(

Printed Name and Signature


Clinical Coordinator
PRC I.D. No.: __________ Valid Until:
_________
PNA I.D. No.: _________ Valid Until:
__________
Date document is signed: ______ Time: ____

Concurred by:
)

Printed Name and Signature


Chief Nurse of the Hospital

SUPERVISED BY
Clinical Instructor
Name and Signature

Concurred by:
)

Printed Name and Signature


Chief Nurse of the Hospital

Approved by:
(
Printed Name and Signature
)
Dean

PRC I.D. No.: _________ Valid Until: ________

PRC I.D. No.: ________ Valid Until: ________

PRC I.D. No.: ______ Valid Until: _________

PNA I.D. No.: ________ Valid Until: ________

PNA I.D. No.: _______ Valid Until: ________

PNA I.D. No.: _____ Valid Until: _________

Date document is signed: _____ Time: _____

Date document is signed: _____ Time: _____

Date document is signed: ____ Time: _____

Please specify Highest Nursing Degree


Earned:
__________________________________

Please specify Highest Nursing Degree


Earned:
_________________________________

Please specify Highest Nursing Degree


Earned:
____________________________________

Please specify Highest Nursing Degree


Earned:
ODC Form 1B
___________________________________
ASSISTED DELIVERY

FORM

(STRICTLY NO DESIGNATES)

Our Lady of Fatima University


Esperanza St., Hilltop Mansion, Lagro, Quezon City
ASSISTED DELIVERY in
_________________________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student___________________________________________________________________________________________________
Concurred
Date Performed
Patients INITIAL
Only by:
PROCEDURE
Noted by:
AndName and Signature
______________________
(
Printed
)
(
Printed Name and
Signature
)
PERFORMED

Time Started

Case Number

Clinical Coordinator (not applicable for Chief Nurse of the Hospital


ASSISTED DELIVERY
Lying-In
PRC I.D. No.: __________ ValidBirthing/
Until:
PRC
I.D. No.: _________ Valid Until: ________
Clinics/Homes)
_________
PNA I.D. No.: _________ Valid Until:
PNA I.D. No.: ________ Valid Until: ________
__________
Date document is signed: ______ Time:
Date document is signed: _____ Time: _____
_______
Please specify Highest Nursing Degree
Please specify Highest Nursing Degree
Earned:
Earned:
__________________________________
_________________________________

Concurred
by:Nurse
D.R.
(

On Duty
(Name
and
Signature)
Printed Name and Signature
(If Midwife on Duty,
Chief Nurse
of required)
the Hospital
Signature
not

Approved by:
)

PRC I.D. No.: ________ Valid Until: ________

BY
( SUPERVISED
Printed Name
and Signature
Clinical
Instructor
)
Dean
Name and Signature
PRC I.D. No.: ________ Valid Until: _________

PNA I.D. No.: _______ Valid Until: ________

PNA I.D. No.: ________ Valid Until: _________

Date document is signed: _____ Time: _____

Date document is signed: ____ Time:


________
Please specify Highest Nursing Degree
Earned:
___________________________________

Please specify Highest Nursing Degree


Earned:
____________________________________

(STRICTLY NO DESIGNATES)
Our Lady of Fatima University
Esperanza St., Hilltop Mansion, Lagro, Quezon City

ODC Form 1C
CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in


______________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student_________________________________________________________________________________________________
Noted by:
Concurred
by:
Concurred by:
Patients INITIAL
Only
Immediate Newborn Cord
Date
Performed
Nurse
On
Duty
(
Printed
Name and Signature
(
Printed
Name
and
Signature
(
Printed Name
and
Signature
______________________
Care
)
)
)
And
(Name and Signature)
Case Number
PERFORMED
Clinical
Coordinator
Chief Nurse of the Hospital
Chief (If
Nurse
of the Hospital
Time
Started
Midwife
on Duty,
(not applicable for
Indicate where performed
PRC I.D. No.: __________ Valid Until:
PRC I.D. No.: _________ Valid Until:
PRC I.D. No.:
________
Valid
Until:
Signature not required)
Birthing Homes/Lying-in
e.g. D.R, Nursery, ________
_________
________
Clinics/Homes)
NICU,
or________
Home PNA I.D. No.: _______ Valid Until:
PNA I.D. No.: _________ Valid Until:
PNA I.D. No.: ________ Valid
Until:
__________
________

Approved by:
SUPERVISED
BY Signature
(
Printed Name and
)
Clinical Instructor
Dean
Name and Signature
PRC I.D. No.: ______ Valid Until:
_________
PNA I.D. No.: _____ Valid Until: _________

Date document is signed: ______


Time: ____
Please specify Highest Nursing
Degree Earned:

Date document is signed: _____


Time: _____
Please specify Highest Nursing
Degree Earned:

Date document is signed: _____


Time: _____
Please specify Highest Nursing
Degree Earned:

Date document is signed: ____ Time:


___
Please specify Highest Nursing
Degree Earned:

__________________________________

_________________________________

____________________________________

___________________________________

ODC Form 2A

O.R. SCRUB FORM


(STRICTLY NO DESIGNATES)
Major
Our Lady of Fatima University
Esperanza St., Hilltop Mansion, Lagro, Quezon City

SURGICAL SCRUB in ___________________________________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student________________________________________________________________________________________________

Noted by:
Concurred by:
( DatePrinted
Performed
Name and Signature
Patients INITIALS
(
Printed Name and Signature
)
And
(only))
Coordinator______________________
Chief Nurse of the Hospital
TimeClinical
Started
PRC I.D. No.: __________ Valid Until:
PRC
I.D.
No.: _________ Valid Until:
Case Number
_________
________
PNA I.D. No.: _________ Valid Until:
PNA I.D. No.: ________ Valid Until: ________
__________

Approved by:
(
SUPERVISED
Printed Name BY
and Signature
)
Clinical Instructor
Dean
Name and Signature
PRC I.D. No.: ______ Valid Until:
_________
PNA I.D. No.: _____ Valid Until: _________

Date document is signed: ______


Time: ____
Please specify Highest Nursing
Degree Earned:

Date document is signed: _____


Time: _____
Please specify Highest Nursing
Degree Earned:

Concurred by:
(
Printed
O.R.
Name
Nurse
and Signature
On Duty
)
(Name and Signature)
Chief Nurse of the Hospital
PRC I.D. No.: ________ Valid Until:
________
PNA I.D. No.: _______ Valid Until:
________

Date document is signed: _____


Time: _____
Please specify Highest Nursing
Degree Earned:

Date document is signed: ____ Time:


___
Please specify Highest Nursing
Degree Earned:

__________________________________

_________________________________

____________________________________

___________________________________

SURGICAL
PROCEDURE
PERFORMED

(STRICTLY NO DESIGNATES)
Our Lady of Fatima University
Esperanza St., Hilltop Mansion, Lagro, Quezon City

ODC Form 2B
O.R. CIRCULATING
FORM

CIRCULATING ___________________________________________________________________________
HospitaL, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student_____________________________________________________________________________________________

Concurred by:
Noted
Dateby:
Performed
Patients INITIALS
(
Printed
(
Printed Name and Signature
And Name and SignatureOnly
) Time Started
)
______________________
Clinical CoordinatorCase Number
Chief Nurse of the Hospital
PRC I.D. No.: __________ Valid Until:
PRC I.D. No.: _________ Valid Until:
_________
________
PNA I.D. No.: _________ Valid Until:
PNA I.D. No.: ________ Valid Until: ________
__________
Date document is signed: ______ Time:
Date document is signed: _____ Time:
____
_____
Please specify Highest Nursing Degree
Please specify Highest Nursing Degree
Earned:
Earned:
__________________________________
_________________________________

Concurred by:

SURGICAL PROCEDURE
(
)
PERFORMED

O.R. Nurse On Duty


Printed
Signature
(NameName
and and
Signature)

Chief Nurse of the Hospital


PRC I.D. No.: ________ Valid Until:
________
PNA I.D. No.: _______ Valid Until:
________
Date document is signed: _____ Time:
_____
Please specify Highest Nursing Degree
Earned:
____________________________________

(STRICTLY NO DESIGNATES)

Approved by:

SUPERVISED BY

( Clinical
Printed
Name and Signature
Instructor
)Name and Signature
Dean
PRC I.D. No.: ______ Valid Until:
_________
PNA I.D. No.: _____ Valid Until: _________
Date document is signed: ____ Time:
_____
Please specify Highest Nursing Degree
Earned:
___________________________________