ACTUAL DELIVERY in Bicol Regional Training and Teaching HospitalLegazpi City, Albay

Hospital / Home / Lying-In Clinic, Municipality / City / Province

Prepared by: D.R. Form
Printed Name and Signature of Student: OLAYRES,ALLELI R.___________________________________ ACTUAL DELIVERY FORM

Patient's INITIAL Only

Date Performed D.R. Nurse On Duty
(Name and Signature) SUPERVISED BY Clinical Instructor
and Case Number PROCEDURE PERFORMED (If Midwife on Duty, signature not Name and Signature
Time Started (not applicable for Birthing /
required)
Lying-In Clinics / Homes)

Normal Spontaneous Vaginal Delivery

September 6,2014 C.R.A. With Second Degree Laceration Lorna Yanzon, Erlinda M. Baronda, RN, RM, MAN,
12:10 PM 234320 RN, MAN PhD

November 10, 2014 J.C. Normal Spontaneous Vaginal Delivery with Marcelina F. Ludovice, Erlinda M. Baronda, RN, RM, MAN,
10:17 AM 256341 Midline Episiotomy RM, RN PhD

Spontaneous Vaginal Delivery with First

Erlinda M. Baronda, RN, RM, MAN,
November 12, 2014 L.J. Degree Laceration Eugenia D. Hinanay, RN
1:12 PM 92679 PhD

(STRICTLY NO DESIGNATES)
[These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist)