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SAINT MICHAELS COLLEGE OF LAGUNA

Institute of Nursing
Old National Road, City of Bian, Laguna (049) 511-9359 loc 312 Tele fax (02) 520-6749 www.smcl.edu.ph

SURGICAL SCRUB in Hospital, Municipality/City/Province Prepared by: Name of Student Date Performed and Time Started Patients Name Case Number Signature of Student

PROCEDURE PERFORMED
Major Operation

D.R. Nurse/Midwife On Duty

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Administrator, PRC ID No. PNA No. 2012-033209 Date document is signed: Highest Nursing Degree Earned:

Smyrnah D.M Roque Valid Until 0187365 Valid Until October 31, 2012 Time MAN

8-9-14

Concurred by: Chief Nurse, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

SAINT MICHAELS COLLEGE OF LAGUNA


Institute of Nursing
Old National Road, City of Bian, Laguna (049) 511-9359 loc 312 Tele fax (02) 520-6749 www.smcl.edu.ph

SURGICAL SCRUB in Hospital, Municipality/City/Province Prepared by: Name of Student Date Performed and Time Started Patients Name Case Number Signature of Student

PROCEDURE PERFORMED
Minor Operation

D.R. Nurse/Midwife On Duty

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Administrator, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

Concurred by: Chief Nurse, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

SAINT MICHAELS COLLEGE OF LAGUNA


Institute of Nursing
Old National Road, City of Bian, Laguna (049) 511-9359 loc 312 Tele fax (02) 520-6749 www.smcl.edu.ph

IMMEDIATE NEWBORN CARE in Hospital, Municipality/City/Province Prepared by: Name of Student Date Performed and Time Started Patients Name Case Number Signature of Student

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Administrator, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

Concurred by: Chief Nurse, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

SAINT MICHAELS COLLEGE OF LAGUNA


Institute of Nursing
Old National Road, City of Bian, Laguna (049) 511-9359 loc 312 Tele fax (02) 520-6749 www.smcl.edu.ph

ACTUAL DELIVERY in Hospital, Municipality/City/Province Prepared by: Name of Student Date Performed and Time Started Patients Name Case Number Signature of Student

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Administrator, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

Concurred by: Chief Nurse, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

SAINT MICHAELS COLLEGE OF LAGUNA


Institute of Nursing
Old National Road, City of Bian, Laguna (049) 511-9359 loc 312 Tele fax (02) 520-6749 www.smcl.edu.ph

ASSISTED DELIVERY in Hospital, Municipality/City/Province Prepared by: Name of Student Date Performed and Time Started Patients Name Case Number Signature of Student

PROCEDURE PERFORMED

D.R. Nurse/Midwife On Duty

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Administrator, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time

Concurred by: Chief Nurse, PRC ID No. PNA No. Date document is signed: Highest Nursing Degree Earned:

Valid Until Valid Until Time