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O.

R Form 1A
O.R. SCRUB FORM MAJOR

WESTERN MINDANAO STATE UNIVERSITY


Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
SURGICAL SCRUB in
Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)


Case Number

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty


(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: MA. LOURDES M. WEE SIT, R.N., M.N.


Clinical Coordinator, PRC I.D. No.__________ Valid Until:

Approved by: LEILA D. BENITO, R.N., M.N.


Dean, PRC I.D. No. _0106758_ Valid Until: _October 9, 2015_

Date document is signed:


Please specify Highest Nursing Degree Earned:

Date document is signed:


Specify Highest Nursing Degree Earned:

____________
Time:
Master in Nursing

Normal Road, Baliwasan, Zamboanga City, Philippines

Time:
O.R Form 1A
Master
in Nursing
O.R. SCRUB FORM MAJOR

Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
SURGICAL SCRUB in
Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)

SURGICAL PROCEDURE
PERFORMED

Case Number

Noted by: MA. LOURDES WEE SIT, R.N., M.N.


Clinical Coordinator, PRC I.D. No.________ Valid Until:
Date document is signed:
Please specify Highest Nursing Degree Earned:

______________

Time:
Master in Nursing

O.R. Nurse On Duty


(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Approved by: LEILA D. BENITO, R.N.,M.N.


Dean, PRC I.D. No. _0106758_ Valid Until: _October 9, 2015_
Date document is signed:
Specify Highest Nursing Degree Earned:

Time:
Master in Nursing

O.R Form 1B
O.R. CIRCULATING FORM MAJOR

WESTERN MINDANAO STATE UNIVERSITY


Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/

SURGICAL CIRCULATING in

Level III Re-accredited / April 2014


Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)


Case Number

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty


(Name and Signature)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: MA. LOURDES M. WEE SIT, R.N., M.N.


Clinical Coordinator, PRC I.D. No. _________ Valid Until:

Approved by: LEILA D. BENITO, R.N., M.N.


Dean, PRC I.D. No. _0106758_ Valid Until: _October 9, 2015_

Date document is signed:


Please specify Highest Nursing Degree Earned:

Date document is signed:


Specify Highest Nursing Degree Earned:

_______________
Time:
Master in Nursing

Time:
Master in Nursing

D.R Form

ACTUAL DELIVERY FORM

WESTERN MINDANAO STATE UNIVERSITY


Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014

ACTUAL DELIVERY in

Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)

PROCEDURE PERFORMED

Case Number
(not applicable for Birthing /Lying In Clinics /
Homes)

Noted by: MA. LOURDES WEE SIT, R.N., M.N.


Clinical Coordinator, PRC I.D. No__________ Valid Until:
Date document is signed:
Please specify Highest Nursing Degree Earned:

___________

Time:
Master in Nursing

D.R. Nurse On Duty


(Name and Signature)
(If Midwife on Duty,
Signature is not Required)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Approved by: LEILA D. BENITO, R.N., M.N.


Dean, PRC I.D. No. _0106758_ Valid Until: _October 9, 2015_
Date document is signed:
Specify Highest Nursing Degree Earned:

WESTERN MINDANAO STATE UNIVERSITY


Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/
Level III Re-accredited / April 2014
IMMEDIATE CARE OF THE NEWBORN in
Hospital, Municipality / City / Province

Time:
ICNB
Form
Master
in Nursing

IMMEDIATE CARE OF THE


NEWBORN

Prepared by:
Printed Name with Signature of Student:

Date Performed
and
Time Started

Patients INITIALS (only)


Case Number
(not applicable for Birthing /Lying In Clinics /
Homes)

Immediate Newborn Cord Care


PERFORMED

D.R. Nurse On Duty


(Name and Signature)

Indicate where performed e.g. D.R., Nursery,


NICU, or Home

(If Midwife on Duty,


Signature is not Required)

SUPERVISED BY:
Clinical Instructor
Name and Signature

Noted by: MA. LOURDES WEE SIT, R.N., M.N.


Clinical Coordinator, PRC I.D. No_________ Valid Until:

Approved by: LEILA D. BENITO, R.N., M.N.


Dean, PRC I.D. No. _0106758_ Valid Until: _October 9, 2015_

Date document is signed:


Please specify Highest Nursing Degree Earned:

Date document is signed:


Specify Highest Nursing Degree Earned:

____________
Time:
Master in Nursing

Time:
Master in Nursing