O.
R Form 1A
O.R. SCRUB FORM MAJOR
WESTERN MINDANAO STATE UNIVERSITY Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/ Level II Re-accredited / February 2009 SURGICAL SCRUB in Hospital, Municipality / City / Province
Prepared by: Printed Name with Signature of Student:
Date Performed and Time Started
Patients INITIALS (only)
Case Number
SURGICAL PROCEDURE PERFORMED
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor Name and Signature
Noted by: SARAH S. TAUPAN, R.N., M.N., D.P.A Clinical Coordinator, PRC I.D. No. 0150766 Valid Until:
Date document is signed: Please specify Highest Nursing Degree Earned:
January 17, 2015
Approved by: LEILA D. BENITO, R.N., M.N. OIC - Dean, PRC I.D. No.0106758 Valid Until: October 9, 2012
Date document is signed: Specify Highest Nursing Degree Earned: Time: Master in Nursing
Time: Master in Nursing
O.R Form 1B
O.R. CIRCULATING FORM MAJOR
WESTERN MINDANAO STATE UNIVERSITY Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/ Level II Re-accredited / February 2009 SURGICAL SCRUB in Hospital, Municipality / City / Province
Prepared by: Printed Name with Signature of Student:
Date Performed and Time Started
Patients INITIALS (only) Case Number
SURGICAL PROCEDURE PERFORMED
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor Name and Signature
Noted by: SARAH S. TAUPAN, R.N., M.N., D.P.A Clinical Coordinator, PRC I.D. No. 0150766 Valid Until:
Date document is signed: Please specify Highest Nursing Degree Earned:
January 17, 2015
Approved by: LEILA D. BENITO, R.N., M.N. OIC - Dean, PRC I.D. No.0106758 Valid Until: October 9, 2012
Date document is signed: Specify Highest Nursing Degree Earned: Time: Master in Nursing
Time: Master in Nursing
D.R Form
ACTUAL DELIVERY FORM
WESTERN MINDANAO STATE UNIVERSITY Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/ Level II Re-accredited / February 2009 ACTUAL DELIVERY in Hospital, Municipality / City / Province
Prepared by: Printed Name with Signature of Student:
Date Performed and Time Started
Patients INITIALS (only) Case Number
(not applicable for Birthing /Lying In Clinics / Homes)
PROCEDURE PERFORMED
D.R. Nurse On Duty (Name and Signature)
(If Midwife on Duty, Signature is not Required)
SUPERVISED BY: Clinical Instructor Name and Signature
Noted by: SARAH S. TAUPAN, R.N., M.N., D.P.A Clinical Coordinator, PRC I.D. No. 0150766 Valid Until:
Date document is signed: Please specify Highest Nursing Degree Earned:
January 17, 2015
Approved by: LEILA D. BENITO, R.N., M.N. OIC - Dean, PRC I.D. No.0106758 Valid Until: October 9, 2012
Date document is signed: Specify Highest Nursing Degree Earned: Time: Master in Nursing
Time: Master in Nursing
ICBN Form
IMMEDIATE CARE OF THE NEWBORN
WESTERN MINDANAO STATE UNIVERSITY Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: [email protected] / Web-Site: www.wmsu.edu.ph
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)/ Level II Re-accredited / February 2009 ACTUAL DELIVERY in Hospital, Municipality / City / Province
Prepared by: Printed Name with Signature of Student:
Date Performed and Time Started
Patients INITIALS (only) Case Number
(not applicable for Birthing /Lying In Clinics / Homes)
Immediate Newborn Cord Care PERFORMED
Indicate where performed e.g. D.R., Nursery, NICU, or Home
D.R. Nurse On Duty (Name and Signature)
(If Midwife on Duty, Signature is not Required)
SUPERVISED BY: Clinical Instructor Name and Signature
Noted by: SARAH S. TAUPAN, R.N., M.N., D.P.A Clinical Coordinator, PRC I.D. No. 0150766 Valid Until:
Date document is signed: Please specify Highest Nursing Degree Earned:
January 17, 2015
Approved by: LEILA D. BENITO, R.N., M.N. OIC - Dean, PRC I.D. No.0106758 Valid Until: October 9, 2012
Date document is signed: Specify Highest Nursing Degree Earned: Time: Master in Nursing
Time: Master in Nursing
