8/6/2019 OR AND DR NEW FORM

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ACTUAL DELIVERY in __________________________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province

D.R. FORMACTUAL DELIVER

FORM

Prepared by:Printed Name and Signature of Student___________________________________________________

Date Performedand

Started

Patient’s INITIAL Only PROCEDUREPERFORMED

D.R. Nurse on Duty(Name and Signature)(If Midwife on Duty,

Signature not Required)

SUPERVISED BY Clinical Instructor

Name andSignature

Case Number(not applicable for Birthing/

Lying-in Clinics/Homes)

REPUBLIC OF THE PHILIPPINESVISAYAS STATE UNIVERSITY

College of NursingVISCA, BAYBAY CITY, LEYTE

Telefax: (053) 563-7226

8/6/2019 OR AND DR NEW FORM

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Endorsed by : ___________________________________________________ Noted by : _____________________________________________________

(Print Name and Signature) (PrinName and Signature)

Delivery Room Coordinator , PRC ID No. ____________ Valid Until _______ Clinical Coordinator , PRC ID 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:

______________________________

Approved by: ___________________________________________________ (Print Name and Signature)

Dean , PRC ID No. ____________ Valid Until _______ Date Document is signed: ____________________________ Time: _____________ Please specify Highest Nursing Degree Earned: ______________________________

ACTUAL ASSIST in __________________________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province

D.R. FORMACTUAL ASSIST

FORM

Prepared by:Printed Name and Signature of Student___________________________________________________

Date Performedand

Started

Patient’s INITIAL Only PROCEDUREPERFORMED

D.R. Nurse on Duty(Name and Signature)(If Midwife on Duty,

SUPERVISED BY Clinical Instructor

Case Number

REPUBLIC OF THE PHILIPPINESVISAYAS STATE UNIVERSITY

College of NursingVISCA, BAYBAY CITY, LEYTE

Telefax: (053) 563-7226

8/6/2019 OR AND DR NEW FORM

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(not applicable for Birthing/Lying-in Clinics/Homes)

Signature not Required) Name andSignature

Endorsed by : ___________________________________________________ Noted by : _____________________________________________________

(Print Name and Signature) (PrinName and Signature)

Delivery Room Coordinator , PRC ID No.____________ Valid Until _______ Clinical Coordinator , PRC ID 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:

______________________________

Approved by : ___________________________________________________ (Print Name and Signature)

Dean , PRC ID No. ____________ Valid Until _______ Date Document is signed: ____________________________ Time: _____________ Please specify Highest Nursing Degree Earned: ______________________________

8/6/2019 OR AND DR NEW FORM

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IMMEDIATE NEWBORN CORD CARE in __________________________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province

ICNB FORMIMMEDIATE CARE OF TH

NEWBORN FORM

Prepared by:Printed Name and Signature of Student___________________________________________________

Date Performedand

Started

Patient’s INITIAL Only Immediate Newborn CordCare PERFORMED

(Indicate where performede.g. D.R., Nursery, NICU or

Home)

D.R. Nurse on Duty(Name and Signature)(If Midwife on Duty,

Signature not Required)

SUPERVISED BY Clinical Instructor

Name andSignature

Case Number(not applicable for Birthing/

Lying-in Clinics/Homes)

REPUBLIC OF THE PHILIPPINESVISAYAS STATE UNIVERSITY

College of NursingVISCA, BAYBAY CITY, LEYTE

Telefax: (053) 563-7226

8/6/2019 OR AND DR NEW FORM

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Endorsed by : ___________________________________________________ Noted by : _____________________________________________________

(Print Name and Signature) (PrinName and Signature)

Delivery Room Coordinator , PRC ID No.____________ Valid Until _______ Clinical Coordinator , PRC ID 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:

______________________________

Approved by : ___________________________________________________ (Print Name and Signature)

Dean , PRC ID No. ____________ Valid Until _______ Date Document is signed: ____________________________ Time: _____________ Please specify Highest Nursing Degree Earned: ______________________________

SURGICAL SCRUB in __________________________________________________________________ Hospital, Municipality/City/Province

O.R. FORM 1 AO.R. SCRUB FORM

Major

Prepared by:Printed Name and Signature of Student___________________________________________________

Date Performedand

Started

Patient’s INITIAL Only PROCEDUREPERFORMED

O.R. Nurse on Duty(Name and Signature)

SUPERVISED BY Clinical Instructor

Case Number

REPUBLIC OF THE PHILIPPINESVISAYAS STATE UNIVERSITY

College of NursingVISCA, BAYBAY CITY, LEYTE

Telefax: (053) 563-7226

8/6/2019 OR AND DR NEW FORM

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Name andSignature

Endorsed by : ___________________________________________________ Noted by : _____________________________________________________

(Print Name and Signature) (PrinName and Signature)

Operating Room Coordinator , PRC ID No. ____________ Valid Until _______ Clinical Coordinator , PRC ID 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:

______________________________

Approved by : ___________________________________________________ (Print Name and Signature)

Dean , PRC ID No. ____________ Valid Until _______ Date Document is signed: ____________________________ Time: _____________ Please specify Highest Nursing Degree Earned: __________________________

8/6/2019 OR AND DR NEW FORM

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8/6/2019 OR AND DR NEW FORM

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Endorsed by : ___________________________________________________ Noted by : _____________________________________________________

(Print Name and Signature) (PrinName and Signature)

Operating Room Coordinator , PRC ID No. ____________ Valid Until _______ Clinical Coordinator , PRC ID 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:

______________________________

Approved by : ___________________________________________________ (Print Name and Signature)

Dean , PRC ID No. ____________ Valid Until _______ Date Document is signed: ____________________________ Time: _____________ Please specify Highest Nursing Degree Earned: __________________________