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LA CONSOLACION COLLEGE MANILA ODC Form 1

#8 Mendiola St., Mendiola Manila O.R. MAJOR FORM


(02) 736-02035 / (02) 313-0513 / http://www.lccm.edu.ph
Government Recognition Level IV, No. 17 on January 23, 2006

Prepared By (Name of Student): SAYANA, KAYE-ANNE F. Signature of Student: ______________________

DATE TIME CASE PROCEDURE OR NURSE ON


No. NAME OF PATIENT SUPERVISED BY HOSPITAL
PERFORMED STARTED NUMBER PERFORMED DUTY

Total Abdominal Amisola Maternity Hospital


1. 07/22/09 9:45AM Ofelia Calbayar 20015141 Hysterectomy Bilateral Darlene Presa, RN _______________________ Hermosa St., Manugid
Salpingo Oophorectomy Agnes Anne B. Comendador, RN Tondo, Manila

Total Abdominal Amisola Maternity Hospital


_______________________
2. 08/10/09 7:35AM Sheryl Lazaro 20016481 Hysterectomy Bilateral Jo Erespe, RN Hermosa St., Manugid
Agnes Anne B. Comendador, RN
Salpingo Oophorectomy Tondo, Manila

Amisola Maternity Hospital


_______________________
3. 08/11/09 9:28AM Amor Garcia Exploratory Laparatomy Darlene Inasoriam, RN Hermosa St., Manugid
20017538 Agnes Anne B. Comendador, RN
Tondo, Manila

Concurred By:
Chief Nurse

Rosana R. Del fonso, RN, MATNE,


MAN,MST __________________________________ __________________________________ __________________________________
(Signature Over Printed Name) (Signature Over Printed Name) (Signature Over Printed Name) (Signature Over Printed Name)
PRC No: 0138625 Valid Until: Nov. 2010 PRC No: _________ Valid Until: ________ PRC No: _________ Valid Until: ________ PRC No: _________ Valid Until: ________
PNA No: 21125 Valid Until:Dec. 31,2010 PNA No: _________ Valid Until: ________ PNA No: _________ Valid Until: ________ PNA No: _________ Valid Until: ________
Date signed: _________ Time: _________ Date signed: _________ Time: _________ Date signed: _________ Time: _________ Date signed: _________ Time: _________
Highest Nursing Degree Earned: Highest Nursing Degree Earned: ________ Highest Nursing Degree Earned: ________ Highest Nursing Degree Earned: ________

Noted By: Approved By:


Notes:
CoordinatorClinical

Joann P. Bumanglag RN,MAN Alejandro F. Sorita RN, MAN


(Signature Over Printed Name) (Signature Over Printed Name)
PRC No:0239004 Valid Until: July 2011 PRC No:0305011 Valid Until:Dec. 26, 2012
Dean

PNA No: 007252 Valid Until: Dec. 2010 PNA No:007255 Valid Until: Oct. 31, 2010
Date signed: _________ Time: _________ ADPCN No:0860 Valid Until: 2012
Highest Nursing Degree Earned: Master of Date signed: _________ Time: _________
Arts in Nursing Highest Nursing Degree Earned: Master of
Arts in Nursing
F-SCNU-005 Page 1 of 5
(Rev1-January 01, 2010)

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