BATAAN PENINSULA STATE UNIVERSITY
COLLEGE OF NURSING AND MIDWIFERY
Accredited by:
Level:
Date of Accreditation:
SURGICAL SCRUB IN
Prepared by:
Name of Student:
Date Performed
and Time Started
(Not Applicable for Birthing/Lying-In, Clinics/Homes)
09-14-15 | 7:05 AM
09-14-15 | 11:25 AM
09-14-15 | 2:10 PM
09-21-15 | 9:00 AM
12-03-15 | 9:25 AM
Noted by:
DR. JOCELYN FAUSTINO VILLANUEVA, RN
Clinical Coordinator
PRC I.D. no:
Valid until:
PNA no:
Valid until:
Date document is signed:
Highest degree earned:
Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph
ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
3
January 01, 2014
O.R. Form 1-A
ISAAC AND CATALINA MEDICAL CENTER MAJOR O.R. SCRUB FORM
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
(Printed Name & Signature of Student)
Patients Initial Only Supervised by
O.R. Nurse on Duty
Case Number SURGICAL PROCEDURE PEFORMED Clinical Instructor
Name and Signature
Name and Signature
581904 | E.P.O. Exploratory Laparotomy Right Salphingo Oophorectomy
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
023403 | C.N.B. Exploratory Laparotomy Appendectomy Peritoneal Lavage
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
900404 | T.B.R. Repeat Low Transverse Cesarean Section
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
272004 | J.D.O. Open Reduction Internal Fixation Radius Ulnar Left
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
752504 | R.S.E. Cholecystectomy
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
Concurred: Approved by:
DR. RUBY SANTOS MATIBAG, RM, RN
Chief Nurse Dean
0177589 PRC I.D. no: PRC I.D. no: 0285929 / 0142873
JUNE 27, 2018 Valid until: Valid until: FEBRUARY 26, 2019
16170 PNA no: PNA no: 2017-024738
LIFETIME Valid until: Valid until: DECEMBER 31, 2017
Date document is signed: Date document is signed:
DOCTOR OF EDUCATION Highest degree earned: Highest degree earned: DOCTOR OF EDUCATION

Accredited by:
Level:
Date of Accreditation:
SURGICAL CIRCULATING IN
Prepared by:
Name of Student:
Date Performed
and Time Started
(Not Applicable for Birthing/Lying-In, Clinics/Homes)
09-15-15 | 9:00 AM
09-16-15 | 12:40 PM
09-23-15 | 1:42 PM
09-28-15 | 10:30 AM
11-27-15 | 3:30 PM
Noted by:
DR. JOCELYN FAUSTINO VILLANUEVA, RN
Clinical Coordinator
PRC I.D. no:
Valid until:
PNA no:
Valid until:
Date document is signed:
Highest degree earned:
BATAAN PENINSULA STATE UNIVERSITY
COLLEGE OF NURSING AND MIDWIFERY
Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph
ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
3
January 01, 2014
O.R. Form 1-A
ISAAC AND CATALINA MEDICAL CENTER MAJOR O.R. CIRCULATING FORM
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
ARRA BEATRIZ G. CUBEBE
(Printed Name & Signature of Student)
Patients Initial Only Supervised by
O.R. Nurse on Duty
Case Number SURGICAL PROCEDURE PEFORMED Clinical Instructor
Name and Signature
Name and Signature
741904 | R.Y.G. Exploratory Peritoneal Lavage Penrose Drainage
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
351504 | P.C.M. Repeat Lower Segment Cesarean Section Second Degree
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
522004 | A.M.D. Exploratory Cystectomy Right, Appendectomy
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
642004 | M.E.A. Wide Excision Anterior Thigh Mass Right
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
502404 | E.B.C. Open Reduction Internal Fixation Femur Left
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
Concurred: Approved by:
DR. RUBY SANTOS MATIBAG, RM, RN
Chief Nurse Dean
0177589 PRC I.D. no: PRC I.D. no: 0285929 / 0142873
JUNE 27, 2018 Valid until: Valid until: FEBRUARY 26, 2019
16170 PNA no: PNA no: 2017-024738
LIFETIME Valid until: Valid until: DECEMBER 31, 2017
Date document is signed: Date document is signed:
DOCTOR OF EDUCATION Highest degree earned: Highest degree earned: DOCTOR OF EDUCATION
 BATAAN PENINSULA STATE UNIVERSITY
COLLEGE OF NURSING AND MIDWIFERY
Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph

Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
Level: 3
Date of Accreditation: January 01, 2014
O.R. Form 1-A
SURGICAL SCRUB IN ISAAC AND CATALINA MEDICAL CENTER MINOR O.R. SCRUB FORM
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student: ARRA BEATRIZ G. CUBEBE
(Printed Name & Signature of Student)

Patients Initial Only Supervised by

Date Performed O.R. Nurse on Duty
Case Number SURGICAL PROCEDURE PEFORMED Clinical Instructor
and Time Started Name and Signature
(Not Applicable for Birthing/Lying-In, Clinics/Homes) Name and Signature

09-14-15 | 1:40PM 531904 | K.C.Q. Incision and Drainage of Bartholins Abscess

Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
09-14-15 | 2:10PM 900404 | T.B.R. Appendectomy
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
09-21-15 | 11:40AM 182004 | G.B.I. Marsupialization
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
09-28-15 | 1:25PM 914602 | E.G.V. CTT Insertion Right, Jackson Pratt Insertion Left
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.
12-03-15 | 2:35PM 832504 | J.R.K. Fistulectomy
Amarah E. Roxas, R.N. Rachel O. Castillo, R.N., M.A.N.

Noted by: Concurred: Approved by:

DR. JOCELYN FAUSTINO VILLANUEVA, RN DR. RUBY SANTOS MATIBAG, RM, RN

Clinical Coordinator Chief Nurse Dean
PRC I.D. no: 0177589 PRC I.D. no: PRC I.D. no: 0285929 / 0142873
Valid until: JUNE 27, 2018 Valid until: Valid until: FEBRUARY 26, 2019
PNA no: 16170 PNA no: PNA no: 2017-024738
Valid until: LIFETIME Valid until: Valid until: DECEMBER 31, 2017
Date document is signed: Date document is signed: Date document is signed:
Highest degree earned: DOCTOR OF EDUCATION Highest degree earned: Highest degree earned: DOCTOR OF EDUCATION