PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)

General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

SURGICAL SCRUB in OSPITAL NG MAYNILA MEDICAL CENTER, MANILA
Hospital, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student MARIN, PAULA NICOLE ANNE REYES

Date Performed
and
Time Started
Patient's INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY Clinical Instructor
(Name and Signature)
Case Number
















Noted by: JOAN M. OYANGOREN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0422859 Valid Until Dec. 12, 2016
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Science in Nursing
Approved by: DR. GILMORE G. SOLIDUM
(Print Name and Signature)
Dean, PRC I.D. No. 0172020 Valid Until July 27, 2014
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
ODC Form 2A
O.R. SCRUB FORM
MAJOR
ODC Form 2B
O.R. MINOR FORM