Anda di halaman 1dari 4

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Tel. No. (02)859-0812/ Fax No.

(02) 859-0875 PAASCU Level II Re-Accredited Status, November 2011 - November 2016
SURGICAL SCRUB IN____________________JOSE REYES MEMORIAL MEDICAL HOSPITAL________________________________ Hospital, Municipality/City/Province O.R. Form 1A Prepared by: Printed Name with Signature of Student _________DE LEON, MARIA LARISSE S._________
Date Performed and Time Started Patients INITIAL (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)
O.R. SCRUB FORM Major

SUPERVISED BY: Clinical Instructor Name and Signature

SEPTEMBER 13, 2012 9:00 AM SEPTEMBER 20, 2012 9:15 AM SEPTEMBER 21, 2012 12:33 PM

R.C. 776084 A.P. 659103 F.M.G. 556379

EXPLORATORY LAPAROTOMY TAH WITH FS OF ENDOMETRIUM HERNIOTOMY RIGHT

ANNALIZA D. XAVIER, RN LUZVIMINDA A. MALONG, RN LUZVIMINDA A. MALONG, RN

DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN

Prepared by: Printed Name with Signature of Student _________DE LEON, MARIA LARISSE S._________
Date Performed and Time Started Patients INITIAL (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)

O.R. Form 1A
O.R. CIRCULATING FORM

SUPERVISED BY: Clinical Instructor Name and Signature

SEPTEMBER 13, 2012 9:25 AM SEPTEMBER 14, 2012 7:55 AM SEPTEMBER 21, 2012 8:55 AM

D.D. 771626 J.M.G 559176 H.V. 423001

ENUCLEATION, OD POSTERIOR SAGITTAL ANORECTOPLASTY SISTRUNK PROCEDURE (STRICTLY NO DESIGNATES)

GARY A. LIBERAL, RN GARY A. LIBERAL, RN NIEVES M. DE GUZMAN, RN

DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN

(This Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN)

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Tel. No. (02)859-0812/ Fax No. (02) 859-0875 PAASCU Level II Re-Accredited Status, November 2011 - November 2016
ACTUAL DELIVERY IN _____________JUSTICE JOSE ABAD SANTOS GENERAL HOSPITAL____________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province D.R. FORM
ACTUAL DELIVERY FORM

Prepared by: Printed Name with Signature of Student _________DE LEON, MARIA LARISSE S._________
Date Performed and Time Started Patients INITIAL (only) Case Number (not applicable for
Birthing/Lying-in Clinics/Home)

PROCEDURE PERFORMED

D.R. Nurse on Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

AUGUST 17, 2012 5:30 PM AUGUST 17, 2012 9:49 PM AUGUST 18, 2012 4:48 PM

N.D.P. 555066 J.M. 293455 M.A. 292335

NSD NSD NSD

JANE FUMERA, RN JOMECA ESCUYOS, RN MARLON BERENA, RN

VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN

IMMEDIATE NEWBORN CORD CARE IN ________________DONA MARTA LYING-IN, PASAY CITY________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province ICNB FORM Prepared by: Printed Name with Signature of Student ___ _________DE LEON, MARIA LARISSE S._________
Date Performed and Time Started Patients INITIAL (only) Case Number (not applicable for
Birthing/Lying-in Clinics/Home)

IMMEDIATE CARE OF THE NEWBORN FORM

IMMEDIATE NEWBORN CORD CARE PERFORMED


Performed e.g. DR, Nursery , NICU Or Home

D.R. Nurse on Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

OCTOBER 23, 2012 6:58 PM MARCH 10, 2012 12:10 PM MARCH 10, 2012 4:45 PM

M.R.P.A 20119371 E.V.L. 20120047 C.M.D. 20119404

DELIVERY ROOM DELIVERY ROOM DELIVERY ROOM (STRICTLY NO DESIGNATES)

LITA C. GUTIERREZ, RM NORMA C. CRUZ, RM LUCENA D. RUPERTO, RM

VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN

(This Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN)

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Tel. No. (02)859-0812/ Fax No. (02) 859-0875 PAASCU Level II Re-Accredited Status, November 2011 - November 2016
SURGICAL SCRUB IN________________ JOSE REYES MEMORIAL MEDICAL HOSPITAL _________________________ Hospital, Municipality/City/Province O.R. Form 1A Prepared by: Printed Name with Signature of Student __________DELA CRUZ, RJ KING C.__________
Date Performed and Time Started Patients INITIAL (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)
O.R. SCRUB FORM Major

SUPERVISED BY: Clinical Instructor Name and Signature

SEPTEMBER 8, 2012 11:00 AM SEPTEMBER 20, 2012 4:00 PM

EXPLORATORY LAPAROTOMY 774492 2012-0982 S/P CYSTECTOMY LEFT

ROSA LEE SANTOS, RN JOHN KARL BUENO, RN

DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN

O.R. Form 1A
Prepared by: Printed Name with Signature of Student __________DELA CRUZ, RJ KING C.__________
Date Performed and Time Started Patients INITIAL (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty (Name and Signature)
O.R. CIRCULATING FORM

SUPERVISED BY: Clinical Instructor Name and Signature

SEPTEMBER 1, 2012 SEPTEMBER 6, 2012 OCTOBER 23, 2012

772153 773600 E.A. 265809

D EXPLORATORY LAPAROTOMY APPENDECTOMY CESARIAN SECTION (STRICTLY NO DESIGNATES)

EVANGELINE DE LOS REYES, RN CHRISTIAN POLINAG, RN CARL JOSEPH SALATONG, RN

DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN DENNIS SISON, RN, MAN

(This Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN)

Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City Tel. No. (02)859-0812/ Fax No. (02) 859-0875 PAASCU Level II Re-Accredited Status, November 2011 - November 2016
ACTUAL DELIVERY IN ____________________OSPITAL NG TONDO_____________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student __________DELA CRUZ, RJ KING C.__________
Date Performed and Time Started Patients INITIAL (only) Case Number (not applicable for
Birthing/Lying-in Clinics/Home)

D.R. FORM
ACTUAL DELIVERY FORM

PROCEDURE PERFORMED

D.R. Nurse on Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

AUGUST 16, 2012 8:40 AM AUGUST 16, 2012 12:46PM AUGUST 18, 2012 10:38 AM

C.A. 119793 B.P. 119795 B.A. 119804

NSD NSD NSD

CLEO SEVILLA, RN CLEO SEVILLA, RN ROSA MICHELLE, RN

VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN

IMMEDIATE NEWBORN CORD CARE IN _______________OSPITAL NG TONDO__________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province

ICNB FORM
Prepared by: Printed Name with Signature of Student __________DELA CRUZ, RJ KING C.__________
Date Performed and Time Started Patients INITIAL (only) Case Number (not applicable for
Birthing/Lying-in Clinics/Home)

IMMEDIATE CARE OF THE NEWBORN FORM

IMMEDIATE NEWBORN CORD CARE PERFORMED


Performed e.g. DR, Nursery , NICU Or Home

D.R. Nurse on Duty (Name and Signature)


(If Midwife on Duty, Signature Not Required)

SUPERVISED BY: Clinical Instructor Name and Signature

AUGUST 16, 2012 1:39 PM AUGUST 18, 2012 6:57 AM AUGUST 18, 2012 1:55 PM

B.A. 119796 G.M. 119803 B.P. 119805

DELIVERY ROOM DELIVERY ROOM DELIVERY ROOM (STRICTLY NO DESIGNATES)

CLEO SEVILLA, RN ROSA MICHELLE, RN ROSA MICHELLE, RN

VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN VOBELETH P. SALANDANAN, RN, MAN

(This Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN)