BulacanStateUniversity COLLEGE OF NURSING

Guinhawa, City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 DateWhenSchool was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

SURGICAL SCRUB in JOSE B. LINGAD MEMORIAL REGIONAL HOSPITAL Dolores, City of San Fernando, Pampanga Date Performed and Time Started May 10, 2011 11:57 AM-12:28 PM Patient’s INITIALS (only) CASE NUMBER CBC, 275762
Clinical Coordinator

O.R. FORM 1A
MAJOR O.R. SCRUB FORM Supervised by Clinical Instructor (Name and Signature) Alvin A. Isip, RN, MAN

SURGICAL PROCEDURE PERFORMED Indirect Inguinal Hernia Left Reducible

O.R. Nurse On Duty ( Name and Signature) Mercado, Marites T., RN

Student

CTC Number: CCI201121302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd
Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

Bulacan State University COLLEGE OF NURSING
Guinhawa, City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 DateWhenSchool was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

SURGICAL SCRUB in MARY IMMACULATE MATERNITY HOSPITAL Sto. Rosario, City of Malolos, Bulacan Date Performed and Time Started January 2, 2012 12:07- 1:20 PM January 5, 2012 7:30- 8:25 AM Patient’s INITIALS (only) CASE NUMBER MCR 12-002 ESC 12-005 SURGICAL PROCEDURE PERFORMED Exploratory Laparotomy, Left Salpingectomy Low Transverse Caesarian Section 1˚
Clinical Coordinator

O.R. FORM 1A
MAJOR O.R. SCRUB FORM O.R. Nurse On Duty ( Name and Signature) Supervised by Clinical Instructor (Name and Signature) Elvira B. Vitug, RN Elvira B. Vitug, RN

Alvin G. Crisostomo, RN DJ Jhoanna F.de Jesus, RN

Student

CTC Number:CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd
Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

BulacanStateUniversity COLLEGE OF NURSING
Guinhawa, City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 DateWhenSchool was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

SURGICAL SCRUB in JOSE B. LINGAD MEMORIAL REGIONAL HOSPITAL Dolores, City of San Fernando, Pampanga Date Performed and Time Started May 9, 2011 9: 30 AM-11:25 AM May 16, 2011 12:33 PM- 1:10 PM Patient’s INITIALS (only) CASE NUMBER MLS, 313951 RVI, 315403 SURGICAL PROCEDURE PERFORMED Right Total, Left Subtotal Thyroidectomy Emergency Caesarian Section, Live Baby Boy + Bilateral Tubal Ligation
Clinical Coordinator

O.R.FORM 1B
MAJOR O.R. CIRCULATING FORM Supervised by Clinical Instructor (Name and Signature) Alvin A. Isip, RN, MAN Alvin A. Isip, RN, MAN

O.R. Nurse On Duty ( Name and Signature) Edrey S. Vergara , RN Roger D. Amio, RN

Student

CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd
Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

BulacanStateUniversity COLLEGE OF NURSING
Guinhawa, City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

SURGICAL SCRUB in MARY IMMACULATE MATERNITY HOSPITAL O.R. FORM 1B Sto. Rosario, City of Malolos, Bulacan MAJOR O.R. CIRCULATING FORM Date Performed and Time Started January 3, 2012 2:32-3:48 PM Patient’s INITIALS (only) CASE NUMBER CPT 12-005
Clinical Coordinator

SURGICAL PROCEDURE PERFORMED Cholecystectomy

O.R. Nurse On Duty ( Name and Signature) Alvin G. Crisostomo, RN

Supervised by Clinical Instructor (Name and Signature) Elvira B. Vitug, RN

Student

CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd

Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

BulacanStateUniversity COLLEGE OF NURSING
Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

SURGICAL SCRUB in MARY IMMACULATE MATERNITY HOSPITAL Sto. Rosario, City of Malolos, Bulacan Date Performed and Time Started January 8, 20112 1:45 PM Patient’s INITIALS (only) CASE NUMBER MPM 12-009
Clinical Coordinator

O.R. FORM 1C
MINOR FORM Supervised by Clinical Instructor (Name and Signature) Elvira B. Vitug, RN

SURGICAL PROCEDURE PERFORMED Dilatation and Curettage

O.R. Nurse On Duty ( Name and Signature) Concordia M. Hernandez, RN

Student

CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd
Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

Bulacan State University COLLEGE OF NURSING
Guinhawa, City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.coM
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

SURGICAL SCRUB in JOSE B. LINGAD REGIONAL MEMORIAL HOSPITAL Dolores, City of San Fernando, Pampanga Date Performed and Time Started September 18, 2009 8:30 AM April 28, 2011 9:15 AM Patient’s INITIALS (only) CASE NUMBER RC 251695 LL 314252
Clinical Coordinator

O.R. FORM 1C
MINOR FORM Supervised by Clinical Instructor (Name and Signature) Maria Joida R. Ocampo RN, MSN Alvin A. Isip, RN, MAN

SURGICAL PROCEDURE PERFORMED Episiorrhaphy Central Venous Pressure Insertion

O.R. Nurse On Duty ( Name and Signature) Ma. Riza M. Tecson RN Edrey S. Vergara , RN

Student

CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Bulacan State University

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd

Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

COLLEGE OF NURSING
Guinhawa,City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: 2008 Year Graduated from the BSN Program: 2012

Date Performed and Time of Delivery May 24,2011 9:40 am May 27,2011 1:20 pm May 30,2011 4:50 am

ACTUAL DELIVERY SCRUB in CALUMPIT DISTRICT HOSPITAL D.R. FORM 1D Caniogan, Calumpit, Bulacan ACTUAL DELIVERY FORM Patient’s INITIALS (only) Supervised by PROCEDURE D.R. Nurse On Duty Clinical Instructor CASE NUMBER PERFORMED ( Name and Signature) (Name and Signature) LND, 167720 AD, 138511 MEP, 164928
Clinical Coordinator

Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN

Daisy Reyes, RN Daisy Reyes, RN Daisy Reyes, RN

Student

CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JESSICA MARIE D.R. BARTOLOME

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd
Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

Bulacan State University

COLLEGE OF NURSING
Guinhawa, City of Malolos, Bulacan (044) 791-94-00 bulsu@yahoo.com
NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

IMMEDIATE NEWBORN CORD CARE in CALUMPIT DISTRICT HOSPITAL Caniogan, Calumpit, Bulacan Patient’s INITIALS (only) Date Performed and Immediate Newborn Cord Care Time of Delivery May 21, 2011 8:05 PM May 23, 2011 9:45 AM May 27, 2011 6:15 AM CASE NUMBER B.B.M 165174 B.B.P 166105 B.B.T 166034
Clinical Coordinator

ICNB FORM 1E
IMMEDIATE CARE OF THE NEWBORN FORM

Area Performed Delivery Room Delivery Room Delivery Room

D.R. Nurse On Duty ( Name and Signature) Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN

Supervised by Clinical Instructor (Name and Signature) Daisy S. Reyes, RN Daisy S. Reyes, RN Daisy S. Reyes, RN

JESSICA MARIE D.R. BARTOLOME Student
CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

Dean

JENNIFER S. CENTENO, RN, MSN

LOIDA O. CRESPO, RN, MSN, MAEd
Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

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