ST.

ANTHONY’S COLLEGE
NURSING DEPARTMENT ODC Form 1A
ACTUAL DELIVERY FORM
San Jose, Antique
(036) 540-9196/540-9237/ Fax. No. (036) 540-9971/info@sac.edu.ph/www.sac.edu.ph

ACTUAL DELIVERY in: ANGEL SALAZAR MEMORIAL GENERAL HOSPITAL/ SAN JOSE, ANTIQUE
Prepared by:
Printed Name and Signature of Student: JOSHUA E. ESPINO
Date Performed Patient’s INITIALS (only) D.R. NURSE ON DUTY SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-In Clinics/Homes) (If Midwife on Duty, Signature Not Required) Name and Signature

AUGUST M.B. NORMAL SPONTANEOUS VAGINAL DELIVERY GERALYN ELENA H. PAGTANAC R.N.,R.M HELEN GRACE J. SALVADO R.N.,M.N
23,2017 CASE NUMBER 174
11:23 AM

JANUARY 23, 2019 M.C.C. NORMAL SPONTANEOUS VAGINAL DELIVERY GERALYN ELENA H. PAGTANAC R.N.,R.M HELEN GRACE J. SALVADO R.N.,M.N
8:20 AM CASE NUMBER 240

JANUARY 23, 2019 R.F.B. NORMAL SPONTANEOUS VAGINAL DELIVERY GERALYN ELENA H. PAGTANAC R.N.,R.M HELEN GRACE J. SALVADO R.N.,M.N
11:04 AM CASE NUMBER 241

Noted: SANDRA T. GRUY, MAN, RN Approved: ARIS KENDELL R. BUNGABONG, MAN, RN

Clinical Coordinator OIC Dean
PRC ID No.: 0286688 Valid Until: 12-25-2019 PRC ID No.: 0582192 Valid Until: 07-17-2021
Date document is signed: ________ Time: _________________ Date document is signed: ________ Time: ______________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 ST. ANTHONY’S COLLEGE
ODC Form 1A
NURSING DEPARTMENT IMMEDIATE CARE OF THE
San Jose, Antique NEWBORN FORM
(036) 540-9196/540-9237/ Fax. No. (036) 540-9971/info@sac.edu.ph/www.sac.edu.ph

IMMEDIATE NEWBORN CARE in: ANGEL SALAZAR MEMORIAL GENERAL HOSPITAL/ SAN JOSE, ANTIQUE
Prepared by:
Printed Name and Signature of Student: JOSHUA E. ESPINO
Date Performed Patient’s INITIALS (only) D.R. Nurse On Duty SUPERVISED BY
PROCEDURE PERFORMED
and (Name and Signature) Clinical Instructor
Time Started
Case Number ASSISTED DELIVERY
(not applicable for Birthing/Lying-In Clinics/Homes) (If Midwife on Duty, Signature Not Required) Name and Signature

JANUARY BABY BOY N. IMMEDIATE NEW BORN CARE GERALYN ELENA H. PAGTANAC R.N.,R.M HELEN GRACE J. SALVADO R.N.,M.N
22,2019 CASE NUMBER 233
11:01 AM

AUGUST BABY BOY G. IMMEDIATE NEW BORN CARE GERALYN ELENA H. PAGTANAC R.N.,R.M HELEN GRACE J. SALVADO R.N.,M.N
1,2019, 2019 CASE NUMBER 5
10:30 AM

AUGUST 1, BABY GIRL A. IMMEDIATE NEW BORN CARE GERALYN ELENA H. PAGTANAC R.N.,R.M HELEN GRACE J. SALVADO R.N.,M.N
2019 CASE NUMBER 7
11:34 AM

Noted: SANDRA T. GRUY, MAN, RN Approved: ARIS KENDELL R. BUNGABONG, MAN, RN

Clinical Coordinator OIC Dean
PRC ID No.: 0286688 Valid Until: 12-25-2019 PRC ID No.: 0582192 Valid Until: 07-17-2021
Date document is signed: ________ Time: _________________ Date document is signed: ________ Time: ______________
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING