PRC FORM s.y. 2010-2011

8/8/2019 PRC FORM s.y. 2010-2011

1/5

ARELLANO UNIVERSITY

COLLEGE of NURSING

2600 Legarda St., Sampaloc, Manila

7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph

PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) 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

SURGICAL PROCEDURE

PERFORMED

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY

Clinical instructor

Name and Signature

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN

Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013

Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________

Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN

ODC Form 2A

O.R. SCRUB MAJOR FOR

8/8/2019 PRC FORM s.y. 2010-2011

2/5

ARELLANO

NIVERSITY

COLLEGE

G

Legarda

,

ampal

,

anila

LOC

, !

"

ax,# # #

arellano.edu.ph$ %

CUCOALevel

e-Accredi

ed

atus

&

"

ebruary

to

"

ebruary

'

URGICAL

CRUB&

inor) in( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

)

ospital

)

ome/Lying-inClinic,

unicipality/City/Province0

1 2 3 4 1 2

5

6

7

8

0

1

i9

@

2

5

NameandSiA

natureB

C

Student( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( ( (

D

ate0

erformed

and

TimeStarted

0

atientsINITIALOnl7

E

aseNumber

SURGICAL0

ROCEDURE0

ERFORMED

O.R.NurseOnDutyF

NameandSiA

nature)

SUP

Clini

Name

otedby:LEONARDOM.NUESTROI

R.,RN,MAN Approvedby:ROBERTOC.SOMBILLO,RN,RM,MAN

Clinical Coordinator, PRCI.D.

o. ! ! P

Q

alidUntil

arch

,

Dean, PRCI.D.

o. P

Q

alidUntil August

,

Datedocument issigned:R R R R R R R R R R R R R R R R

S

ime:R R R R R R R R R R R R R R

Datedocument issigned:R R R R R R R R R R R R R R R R

S

ime:R R R R R R R

)

ighest

ursingDegreeEarned:BSN,

AN)

ighestNursingDegreeEarned:BSN,

idwi

ery,

AN

O

O.R.SC

8/8/2019 PRC FORM s.y. 2010-2011

3/5

ARELLANOUNIVERSITY

COLLEGEofNURSINGT U V V

LegardaSt., Sampaloc, ManilaW X Y W X W `

LOCT T T

/210,W X a X a

09b

ax, www.arellano.edu.ph

PACUCOALevel IIRe-AccreditedStatus

c

b

ebruary2010to

b

ebruary2015)

ACTUALDELIVERY ind d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d

e

ospital/Home/Lying-inClinic, Municipality/City/Province

Preparedby:

PrintedNameandSif

natureofStudentd d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d d

DatePerformed

and

TimeStarted

PatientsINITIALOnly

CaseNumberg

notapplicableforBirthing/Lying-

inClinic/Home)

PROCEDURE

PERFORMED

D.R.NurseOnDutyh

NameandSif

nature)h

IfMidwifeonDuty,Sif

natureNotRequired)

SUPE

Clinica

Namea

Notedby:LEONARDOM.NUESTROi


Clinical Coordinator, PRCI.D.No.190198ValidUntil March25, 2013 Dean, PRCI.D.No.0172832 ValidUntil August02, 2013

Datedocument issigned:p p p p p p p p p p p p p p p p

Time:p p p p p p p p p p p p p p

Datedocument issigned:p p p p p p p p p p p p p p p p

Time:p p p p p p p

HighestNursingDegreeEarned:BSN, MAN HighestNursingDegreeEarned:BSN, Midwifery, MAN

O

ACTUA

8/8/2019 PRC FORM s.y. 2010-2011

4/5

ARELLANOUNIVERSITY

COLLEGEofNURSING

2600LegardaSt., Sampaloc, Manila

7347371LOC222/210, 7353509q



r

q

ebruary2010to

q

ebruary2015)

ASSISTEDDELIVERY ins s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s

Hospital/Home/Lying-inClinic, Municipality/City/Province

Preparedby:

PrintedNameandSit

natureofStudents s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s s

DatePerformed

and

TimeStarted

PatientsINITIALOnly

CaseNumberu


inClinic/Home)

PROCEDURE

PERFORMED

ASSISTEDDELIVERY

D.R.NurseOnDutyv

NameandSit

nature)v

IfMidwifeonDuty,Sit

natureNotRequired)

SUPE

Clinica

Namea

Notedby:LEONARDOM.NUESTROw



Datedocument issigned:x x x x x x x x x x x x x x x x Time:x x x x x x x x x x x x x x Datedocument issigned:x x x x x x x x x x x x x x x x Time:x x x x x x x


O

ASSISTE

8/8/2019 PRC FORM s.y. 2010-2011

5/5

ARELLANOUNIVERSITY

COLLEGEofNURSING

2600LegardaSt., Sampaloc, Manila

7347371LOC222/210, 7353509y



y

ebruary2010to

y

ebruary2015)

IMMEDIATENEWBORNCORDCARE in

Hospital/Home/Lying-inClinic, Municipality/City/Province

Preparedby:

PrintedNameandSi

natureofStudent

DatePerformed

and

TimeStarted

PatientsINITIALOnly

CaseNumber


inClinic/Home)

ImmediateNewbornCordCare

PERFORMED

Indicatewhereperformede.g.D.R.,

Nursery, NICU, orHome

D.R.NurseOnDuty

NameandSi

nature)

IfMidwifeonDuty,Si

natureNotRequired)

SUPE

Clinica

Namea

Notedby:LEONARDOM.NUESTRO



Datedocument issigned: Time: Datedocument issigned: Time:


O

O.R.SC

Documents

PRC FORM s.y. 2010-2011