ODC Form 2A

O.R. SCRUB FORM

UNIVERSITY OF PANGASINAN MAJOR
Phinma Education Network
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB in: Region I Medical Center, Dagupan City, Pangasinan

Prepared by:
Printed Name with Signature of Student JUNIO, Avril Bato

Date Performed Patient’s initials SURGICAL PROCEDURE O. R. Nurse on Duty SUPERVISED BY

AND
Case Number PERFORMED [Name AND Signature]
Time Started
A.B.C. Kris C. Aquino,RN Rhoan D. Ogayon, RN
December 01, 2009
Appendectomy
7:45 AM 123456
December 02, 2009 D.E.F. Kris C. Aquino,RN Rhoan D. Ogayon, RN
8:50AM Cholecystectomy
234567
Kris C. Aquino,RN Rhoan D. Ogayon, RN
G.H.I.
December 03, 2009 Cheiloplasty
9:30AM 345678
Kris C. Aquino,RN Rhoan D. Ogayon, RN
December 04, 2009 J.K.L. Extra Capsular Cataract Extraction
10:45AM with Posterior Chamber Intraocular
456789 Lens
December 05, 2009 M.N.O. Kris C. Aquino,RN Rhoan D. Ogayon, RN
1:57PM Low Transverse Caesarean Section
567890

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC I.D. No. 0133422 Valid Until: July 27, 2011 Dean, PRC I.D. No. 100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PHd
 ODC Form 2B
O.R. SCRUB FORM
UNIVERSITY OF PANGASINAN MINOR
Phinma Education Network
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB in: Region I Medical Center, Dagupan City, Pangasinan

Prepared by:
Printed Name with Signature of Student JUNIO, Avril Bato

Date Performed Patient’s initials SURGICAL PROCEDURE O. R. Nurse on Duty SUPERVISED BY

AND
Case Number PERFORMED [Name AND Signature]
Time Started
December 01, 2009 A.B.C. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Circumcision
7:45 AM 123456
December 02, 2009 D.E.F. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Suturing
8:50AM 234567
December 03, 2009 G.H.I. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Debridement
9:30AM 345678
December 04, 2009 J.K.L. Kris C. Aquino,RN Rhoan D. Ogayon, RN
10:45AM Incision and Drainage
456789
December 05, 2009 M.N.O. Kris C. Aquino,RN Rhoan D. Ogayon, RN
1:57PM Excision
567890

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No. 0133422 Valid Until: July 27, 20011 Dean, PRC No. 100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PHd
 ODC Form 1A
UNIVERSITY OF PANGASINAN ACTUAL DELIVERY FORM
Phinma Education Network
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

ACTUAL DELIVERY in: Region I Medical Center, Dagupan City, Pangasinan

Prepared by:
Printed Name with Signature of Student JUNIO, Avril Bato

Date Performed Patient’s initials PROCEDURE D. R. Nurse on Duty SUPERVISED BY

AND
Case Number PERFORMED [Name AND Signature]
Time Started
December 01, 2009 A.B.C. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
7:45 AM 123456
December 02, 2009 D.E.F. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
8:50AM 234567
December 03, 2009 G.H.I James D. Yap, RM Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
9:30AM 345678
December 04, 2009 J.K.L. Kris C. Aquino,RN Rhoan D. Ogayon, RN
10:45AM Normal Spontaneous Delivery
456789
December 05, 2009 M.N.O. Kris C. Aquino,RN Rhoan D. Ogayon, RN
1:57PM Normal Spontaneous Delivery
567890

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No. 0133422 Valid Until: July 27, 20011 Dean, PRC No. 100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PHd
 ODC Form 1C
UNIVERSITY OF PANGASINAN ASSISTED DELIVERY
Phinma Education Network FORM
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

ACTUAL DELIVERY in: Region I Medical Center, Dagupan City, Pangasinan

Prepared by:
Printed Name with Signature of Student JUNIO, Avril Bato

Date Performed Patient’s initials PROCEDURE

D. R. Nurse on Duty SUPERVISED BY
AND PERFORMED
Case Number [Name AND Signature]
Time Started ASSISTED DELIVERY
December 01, 2009 A.B.C. Kris C. Aquino, RN Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
7:45 AM 123456
December 02, 2009 D.E.F. James Yap, RM Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
8:50AM 234567
December 03, 2009 G.H.I. Kris C. Aquino, RN Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
9:30AM 345678
December 04, 2009 J.K.L. James Yap, RM Rhoan D. Ogayon, RN
10:45AM Normal Spontaneous Delivery
456789
December 05, 2009 M.N.O. Kris C. Aquino, RN Rhoan D. Ogayon, RN
1:57PM Normal Spontaneous Delivery
567890

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No. 0133422 Valid Until: July 27, 20011 Dean, PRC No. 100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PHd
 ODC Form 1C
UNIVERSITY OF PANGASINAN CORD CARE FORM
Phinma Education Network
Arellano St., Dagupan City
Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level I PACUCOA; Year Granted: March 05, 2007)

IMMEDIATE NEWBORN CORD CARE in: Region I Medical Center, Dagupan City, Pangasinan

Prepared by:
Printed Name and Signature of Student JUNIO, Avril Bato

Date Performed Patient’s initials Immediate Newborn Cord Care

PERFORMED SUPERVISED BY
AND (Please indicate here where the procedure
Nurse On Duty
Time Started Case Number
was performed eg. D.R., Nursery, Home)

December 01, 2009 A.B.C. Normal Spontaneous Delivery Kris C. Aquino,RN Rhoan D. Ogayon, RN
7:45 AM 123456 Delivery Room
December 02, 2009 D.E.F. Normal Spontaneous Delivery Kris C. Aquino,RN Rhoan D. Ogayon, RN
8:50AM 234567 Delivery Room
December 03, 2009 G.H.I. Normal Spontaneous Delivery Kris C. Aquino,RN Rhoan D. Ogayon, RN
9:30AM 345678 Delivery Room
December 04, 2009 J.K.L. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
10:45AM
456789 Delivery Room
December 05, 2009 M.N.O. Kris C. Aquino,RN Rhoan D. Ogayon, RN
Normal Spontaneous Delivery
1:57PM
567890 Delivery Room

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No. 0133422 Valid Until: July 27, 20011 Dean, PRC No. 100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PHd