Republic of the Philippines UNIVERSITY OF EASTERN PHILIPPINES University Town, Northern Samar COLLEGE OF NURSING (055)251-8360 ACCREDITING AGENCY
OF CHARTERED COLLEGES AND UNIVERSITIES IN THE PHILIPPINES, INC. LEVEL 1 ACCREDITED DECEMBER 16, 2009 TO DECEMBER 15, 2012 ACTUAL DELIVERY in: EASTERN SAMAR PROVINCIAL HOSPITAL Borongan E. Samar Prepared by: QBCDE JDNSNH
Date Performed and Time Started December 22, 2009 Time Started : 05:01 AM December 25, 2009 Time Started : 01:00 PM May 11, 2010 Time Started: 2:30 AM RONA, R.N., M.A.N.
Clinical Coordinator Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0178033 Valid until : May 11, 2012 PNA No. : 2011-062245 Valid Until : October 31, 2011
ODC FORM 1A ACTUAL DELIVERY FORM
SUPERVISED BY Name and Signature of Clinical Instructor
Patients Initials Case Number
Procedure Performed
Nurse On Duty (Name and Signature)
H. T. Case Number : 14-04-86 A. O. Case Number : 17-09-31 L. B. Case Number: 23-32-83
Handled Delivery I D. G, RN Handled Delivery ADOR, RN Handled Delivery IME, RN JEA, RN, MAN MAR, R.N., MAN M L. C, R.N., MAN
MARIA, R.N., M.A.N.
Dean Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0147802 Valid until : March 8, 2014 PNA No. : 2011-062246 Valid Until : October 31, 2011 ADPCN No. : 0453 Valid Until : December 2011
Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES University Town, Northern Samar COLLEGE OF NURSING (055)251-8360 ACCREDITING AGENCY OF CHARTERED COLLEGES AND UNIVERSITIES IN THE PHILIPPINES, INC. LEVEL 1 ACCREDITED DECEMBER 16, 2009 TO DECEMBER 15, 2012 ACTUAL DELIVERY in: EASTERN SAMAR PROVINCIAL HOSPITAL Borongan E. Samar Prepared by: LKAA A. AA
Date Performed and Time Started December 24, 2009 Time Started : 08:00 PM May 10, 2010 Time Started: 12:28 PM May 14, 2010 Time started: 12:46 PM RO, R.N., M.A.N.
Clinical Coordinator Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0178033 Valid until : May 11, 2012 PNA No. : 2011-062245 Valid Until : October 31, 2011
ODC FORM 1B ASSISTED DELIVERY FORM
Patients Initials Case Number
Procedure Performed
Nurse On Duty (Name and Signature)
SUPERVISED BY Name and Signature of Clinical Instructor
G. P. Case Number : 23-26-07 P. B. Case Number: 23-32-68 R. B. Case Number : 13-32-26
Assisted Delivery R, RN Assisted Delivery M, RN Assisted Delivery M, RN J, RN,MAN JO, RN,MAN J, RN,MAN
MA, R.N., M.A.N.
Dean Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0147802 Valid until : March 8, 2014 PNA No. : 2011-062246 Valid Until : October 31, 2011 ADPCN No. : 0453 Valid Until : December 2011
Republic of the Philippines UNIVERSITY OF EASTERN PHILIPPINES
University Town, Northern Samar COLLEGE OF NURSING (055)251-8360 ACCREDITING AGENCY OF CHARTERED COLLEGES AND UNIVERSITIES IN THE PHILIPPINES, INC. LEVEL 1 ACCREDITED DECEMBER 16, 2009 TO DECEMBER 15, 2012 IMMEDIATE NEWBORN CORD CARE in: EASTERN SAMAR PROVINCIAL HOSPITAL Borongan E. Samar Prepared by: KAA A. AA
Date Performed and Time Started December 21, 2009 Time Started : 07:50 AM December 23, 2009 Time Started : 08:25 PM December 24, 2009 Time Started: 10:28 PM Patients Initials Case Number Immediate Newborn Cord Care PERFORMED At Northern Samar Provincial Hospital Immediate Newborn Cord Care MA , RN MAR , R.N., MAN Nurse On Duty (Name and Signature)
ODC FORM 1C CORDCARE FORM
SUPERVISED BY Name and Signature of Clinical Instructor
B Bb boy Cases Number : 23-40-75
B Bb Girl Cases Number : 10-04-83
Immediate Newborn Cord Care RNA, RN JJR , RN,MAN
A Bb Girl Case Number: 23-02-10
Immediate Newborn Cord Care RI , RN JEAN , RN,MAN
RO, R.N., M.A.N.
Clinical Coordinator Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0178033 Valid until : May 11, 2012 PNA No. : 2011-062245 Valid Until : October 31, 2011
MA, R.N., M.A.N.
Dean Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0147802 Valid until : March 8, 2014 PNA No. : 2011-062246 Valid Until : October 31, 2011 ADPCN No. : 0453 Valid Until : December 2011
Republic of the Philippines
UNIVERSITY OF EASTERN PHILIPPINES University Town, Northern Samar COLLEGE OF NURSING (055)251-8360 ACCREDITING AGENCY OF CHARTERED COLLEGES AND UNIVERSITIES IN THE PHILIPPINES, INC. LEVEL 1 ACCREDITED DECEMBER 16, 2009 TO DECEMBER 15, 2012 SURGICAL MAJOR SCRUB in: EASTERN SAMAR PROVINCIAL HOSPITAL Borongan E. Samar Prepared by: KATE ACICA ACEBRON
Date Performed and Time Started October 26, 2010 Time Started : 3:20 PM October 29, 2010 Time Started: 06:30 PM Patients Initials Case Number B.C. Jr. Case Number : 23-26-72 A. C. Case number: 05-60-91 PROCEDURE PERFORMED O.R. Nurse On Duty (name and Signature) M A. R, RN
ODC Form 2A O.R. SCRUB FORM MAJOR
SUPERVISED BY Name and Signature of Clinical Instructor
Explore Laparotomy/ Evacuation of hemiperitoneum Excision of Mass on Palate
RA, RN. MAN CERA, RN, MAN
A. AD , RN
RORA,R.N., M.A.N.
Clinical Coordinator Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0178033 Valid until : May 11, 2012 PNA No. : 2011-062245 Valid Until : October 31, 2011
MAUS,R.N., M.A.N.
Dean Date Signed_____________________ Degree : BSN, RN, MAN PRC No. : 0147802 Valid until : March 8, 2014 PNA No. : 2011-062246 Valid Until : October 31, 2011 ADPCN No. : 0453 Valid Until : December 2011
