8/2/2019 Prc Case Form Cmo 14

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MARTINEZ MEMORIAL COLLEGES198 A. Mabini Street, Maypajo, Caloocan City

Tel. No. 288-4279 / 287-5003

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

Prepared by:

Printed Name and Signature of Student : _________________________________________ 

DATE TIME Patient's INITIAL Only ____________ Case Number 

PROCEDURE PERFORMEDASSISTED DELIVERY

D.R. NURSE ON DUTY( Name and Signature )

SUPERVISED BYClinical Instructor 

Name and Signature

Noted by: Approved by:

( Print Name and Signature ) ( Print Name and Signature )Clinical Coordinator, PRC ID No._____________ Valid Until _________ Dean, 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 _______________ 

ODC Form 1 B

ASSISTED DELIVERY

FORM

8/2/2019 Prc Case Form Cmo 14

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MARTINEZ MEMORIAL COLLEGES 

198 A. Mabini Street, Maypajo, Caloocan CityTel. No. 288-4279 / 287-5003

SURGICAL SCRUB in__________________________________________________ Hospital, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student :_________________________________________ 

DATE TIME PATIENT’S INITIALS ONLY ____________ Case Number 

SURGICAL PROCEDUREPERFORMED

O.R. NURSE ON DUTY( Name and Signature )

SUPERVISED BYClinical Instructor 

Name and Signature

Noted by: Approved by:

( Print Name and Signature ) ( Print Name and Signature )

Clinical Coordinator, PRC ID No._____________ Valid Until _________ Dean, 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 _______________ 

ODC Form 2 B

O.R. CIRCULATING

FORM

8/2/2019 Prc Case Form Cmo 14

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MARTINEZ MEMORIAL COLLEGES 

198 A. Mabini Street, Maypajo, Caloocan CityTel. No. 288-4279 / 287-5003

SURGICAL SCRUB in__________________________________________________ Hospital, Municipality/City/Province

Prepared by:

Printed Name and Signature of Student :_________________________________________ 

DATE TIME PATIENT’S INITIALS ONLY ____________ Case Number 

SURGICAL PROCEDUREPERFORMED

O.R. NURSE ON DUTY( Name and Signature )

SUPERVISED BYClinical Instructor 

Name and Signature

Noted by: Approved by:

( Print Name and Signature ) ( Print Name and Signature )Clinical Coordinator, PRC ID No._____________ Valid Until _________ Dean, 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 _______________ 

ODC Form 2 B

O.R. SCRUB FORM

8/2/2019 Prc Case Form Cmo 14

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MARTINEZ MEMORIAL COLLEGES198 A. Mabini Street, Maypajo, Caloocan City

Tel. No. 288-4279 / 287-5003

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

Prepared by:

Printed Name and Signature of Student :_________________________________________ 

DATE TIME PATIENT’S INITIAL ONLY ____________ Case Number 

PROCEDURE PERFORMED D.R. NURSE ON DUTY( Name and Signature )

SUPERVISED BYClinical Instructor 

Name and Signature

Noted by: Approved by:

( Print Name and Signature ) ( Print Name and Signature )

Clinical Coordinator, PRC ID No._____________ Valid Until _________ Dean, 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 _______________ 

ODC Form 1 A

ACTUAL DELIVERY

FORM

8/2/2019 Prc Case Form Cmo 14

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MARTINEZ MEMORIAL COLLEGES198 A. Mabini Street, Maypajo, Caloocan City

Tel. 288-4279 / 287-5003

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

Prepared by:

Printed Name and Signature of Student :_________________________________________ 

DATE TIME PATIENT’S INITIAL ONLY ____________ Case Number 

Immediate NewbornCord Care Performed

Indicate where Performed

NURSE ON DUTY( Name and Signature )

SUPERVISED BYClinical Instructor 

Name and Signature

Noted by: Approved by:

( Print Name and Signature ) ( Print Name and Signature )Clinical Coordinator, PRC ID No._____________ Valid Until _________ Dean, 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 _______________ 

CORD CARE FORM