QF-S0N-009

EMILIO AGUINALDO COLLEGE-MANILA

1113-1117San Marcelino St., Paco, Manila
521-2710 Loc 5432/www.eac.edu.ph
Level II PACUCOA Accredited

SURGICAL SCRUB in Manila Med Medical Center Manila, Paco Manila

Prepared by: IBRAHIM TAHIR, REHAB A. O.R. Form 1A

Printed Name and signature of Student O.R. SCRUB FORM
Major

Date Performed Patient’s INITIAL Only SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY:
and ____________________ (Name and Signature) Clinical Instructor
Time Started Case Number Name and Signature

3/14/2019 D.B Lesly Valenzuela RN. Ariel M. Ortuoste RN, MAN

Arteriovenous Fistula Creation Left Arm
9:26 am 36596

Noted by: FATIMA B. TENORIO-ASIS RN, RM, MAN Approved by: MARIA THERESA T. SORIANO RN, MSN
Clinical Coordinator Dean
PRC I.D. No. 0320322 Valid Until September 13, 2021 PRC I.D. No. 0272047 Valid Until November 16,2020
PNA No. 2019-2104 Valid Until December 31, 2019 PNA No. 2019-2106 Valid Until December 31, 2019
Date document is signed: Time: ADPCN No. 11-398 Valid Until May 2020
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: Time:
Highest Nursing Degree Earned: Master of Science in Nursing
 QF-S0N-010
EMILIO AGUINALDO COLLEGE-MANILA
1113-1117San Marcelino St., Paco, Manila
521-2710 Loc 5432/www.eac.edu.ph
Level II PACUCOA Accredited

CIRCULATING NURSE in Manila Med Medical Center Manila, Paco Manila

Prepared by: Abdo, Delal Ali

O.R. Form 1B
Printed Name and signature of Student
O.R. CIRCULATING

Date Performed Patient’s INITIAL Only O.R. Nurse on Duty SUPERVISED BY:
and
SURGICAL PROCEDURE PERFORMED
___________________ (Name and Signature) Clinical Instructor
Time Started Case Number Name and Signature

03/01/2019
F.L.E Arthroscopy, Right Knee Rico Colmo Rn Ariel M. Ortuoste RN, MAN
1:32pm
26375

Noted by: FATIMA B. TENORIO-ASIS RN, RM, MAN Approved by: MARIA THERESA T. SORIANO RN, MSN
Clinical Coordinator Dean
PRC I.D. No. 0320322 Valid Until September 13, 2021 PRC I.D. No. 0272047 Valid Until November 16,2020
PNA No. 2019-2104 Valid Until December 31, 2019 PNA No. 2019-2106 Valid Until December 31,
Date document is signed: Time: 2019
Highest Nursing Degree Earned: Master of Arts in Nursing ADPCN No. 11-398 Valid Until May 2020
Date document is signed: Time:
Highest Nursing Degree Earned: Master of Science in
Nursing