UNIVERSITY OF THE VISAYAS

COLLEGE OF NURSING
SUMMARY OF OPERATING ROOM / DELIVERY ROOM CASES

Name of Student: ___________________

Class: _____________ Section: ________

A. OPERATING ROOM
A.1 SCRUB CASES

Date of Surgical SUPERVISING CLINICAL VERIFIED & SCREENED BY

SCRUB CASE # INSTITUTION SURGICAL OPERATION PERFORMED
Operation INSTRUCTOR

I hereby certify that all information given is true and valid.

________________________________ _____________
Student’s Signature Over Printed Name Date Submitted

Noted by: Approved by:

Mrs. Yvonne Y. Peñan RN, MAN Mrs. Yvonne M. Sevilla RM, RN, MAN
Clinical Coordinator Dean, College of Nursing

NOTE: Please attach a photocopy of your cases and performance checklists.

 A.2 CIRCULATING CASES

CIRCULATING Date of Surgical SUPERVISING CLINICAL VERIFIED & SCREENED BY

INSTITUTION SURGICAL OPERATION PERFORMED
CASE # Operation INSTRUCTOR

I hereby certify that all information given is true and valid.

________________________________ _____________
Student’s Signature over Printed Name Date Submitted

Noted by: Approved by:

Mrs. Yvonne Y. Peñan RN, MAN Mrs. Yvonne M. Sevilla RM, RN, MAN
Clinical Coordinator Dean, College of Nursing

NOTE: Please attach a photocopy of your cases and performance checklists.

 A.3 MINOR CASES

CIRCULATING Date of Surgical SUPERVISING CLINICAL VERIFIED & SCREENED BY

INSTITUTION SURGICAL OPERATION PERFORMED
CASE # Operation INSTRUCTOR

Vicente Sotto Memorial Medical Center Ms. Agnes L . Resaba RN, MAN

I hereby certify that all information given is true and valid.

________________________________ _____________
Student’s Signature over Printed Name Date Submitted

Noted by: Approved by:

Mrs. Yvonne Y. Peñan RN, MAN Mrs. Yvonne M. Sevilla RM, RN, MAN
Clinical Coordinator Dean, College of Nursing

NOTE: Please attach a photocopy of your cases and performance checklists.

 B. DELIVERY ROOM
B.1 HANDLED CASES

HANDLED SUPERVISING CLINICAL VERIFIED & SCREENED BY

Date of Delivery INSTITUTION PROCEDURE PERFORMED
CASE # INSTRUCTOR

Vicente Sotto Memorial Medical Center Normal Spontaneous Vaginal Delivery Mrs. Emelita C. Las Marias RN, MAN

Normal Spontaneous Vaginal Delivery

Normal Spontaneous Vaginal Delivery

I hereby certify that all information given is true and valid.

________________________________ _____________
Student’s Signature over Printed Name Date Submitted

Noted by: Approved by:

Mrs. Yvonne Y. Peñan RN, MAN Mrs. Yvonne M. Sevilla RM, RN, MAN
Clinical Coordinator Dean, College of Nursing

NOTE: Please attach a photocopy of your cases and performance checklists.

 B.2 ASSISTED CASES

ASSISTED SUPERVISING CLINICAL VERIFIED & SCREENED BY

Date of Delivery INSTITUTION PROCEDURE PERFORMED
CASE # INSTRUCTOR

I hereby certify that all information given is true and valid.

_________________________________ _____________
Student’s Signature Over Printed Name Date Submitted

Noted by: Approved by:

Mrs. Yvonne Y. Peñan RN, MAN Mrs. Yvonne M. Sevilla RM, RN, MAN
Clinical Coordinator Dean, College of Nursing

NOTE: Please attach a photocopy of your cases and performance checklists.

 B.3 IMMEDIATE NEWBORN CORD CARE CASES

NEWBORN Date / Time of

SUPERVISING CLINICAL VERIFIED & SCREENED BY
CORD CARE Newborn Cord INSTITUTION PROCEDURE PERFORMED
INSTRUCTOR
CASE # Care

I hereby certify that all information given is true and valid.

________________________________ _____________
Student’s Signature over Printed Name Date Submitted

Noted by: Approved by:

Mrs. Yvonne Y. Peñan RN, MAN Mrs. Yvonne M. Sevilla RM, RN, MAN
Clinical Coordinator Dean, College of Nursing

NOTE: Please attach a photocopy of your cases and performance checklists.