MINDANAO STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: AmaiPakpak Medical Center, Marawi City, Lanao del Sur
Hospital/Home/Lying-in, Municipality/City/Province
ODC Form 1A
ACTUAL DELIVERY
FORM
Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA
Date Performed
and
Time Started
Patients INITIALS (only)
Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)
PROCEDURE PERFORMED
January 15, 2012
4:50 PM
R. G.
14-11-51
Normal Spontaneous Vaginal Delivery
March 7, 2013
5:10 PM
R. M.
14-66-59
Normal Spontaneous Vaginal Delivery
H. I.
09-73-87
Normal Spontaneous Vaginal Delivery
March 9, 2013
10:05 PM
Noted by: ROMANOFF RAKI-IN, RN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________
(NSVD)
(NSVD)
(NSVD)
D.R. Nurse on Duty
(Name and Signature)
(If Midwife on Duty, Signature
Not Required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Emily M. Abbas
PRC Number: 0709999
Valid Until:
Shiennah O. Lunag, RN
PRC Number: 0545623
Valid Until: March 13, 2015
Farida Lawa, RN
PRC Number:
Valid Until:
Shiennah O. Lunag, RN
PRC Number: 0545623
Valid Until: March 13, 2015
Farida Lawa, RN
PRC Number:
Valid Until:
Shiennah O. Lunag, RN
PRC Number: 0545623
Valid Until: March 13, 2015
Valid Until: March 17, 2016
Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D
(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Time: __________________
Date document is signed: ______________
Time:
Please specify highest Nursing Degree Earned:
Arts in Nursing_____
_______________________
Please specify highest Nursing Degree Earned: Master of
MINDANAO STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
SURGICAL SCRUB in: AmaiPakpak Medical Center, Marawi City, Lanao del Sur
Hospital/Home/Lying-in, Municipality/City/ Province
ODC Form 2A
O.R. SCRUB FORM
Major
Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA
Date Performed
and
Time Started
Patients INITIALS (only)
Case Number
SURGICAL PROCEDURE
PERFORMED
September 28,
2011
12:40 AM
N. B. B.
10-94-93
Appendectomy Lavage
October 2, 2011
10:06 PM
A. L. G.
10-94-93
Repeat Cesarean Section
Noted by: ROMANOFF RAKI-IN, RN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________
O.R. Nurse on Duty
(Name and Signature)
June Michael Claret, RN
PRC Number: 0410256
Valid Until:
K. Firmo, RN
PRC Number:
Valid Until:
SUPERVISED BY
Clinical Instructor
Name and Signature
Albert Dan Mero, RN
PRC Number:
Valid Until:
Albert Dan Mero, RN
PRC Number:
Valid Until:
Valid Until: March 17, 2016
Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D
(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Time: __________________
Date document is signed: ______________
Time:
Please specify highest Nursing Degree Earned:
Arts in Nursing_____
_______________________
Please specify highest Nursing Degree Earned: Master of
MINDANAO STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
SURGICAL SCRUB in: Gregorio T. Lluch Memorial Hospital, Iligan City, Lanao del Norte
Hospital/Home/Lying-in, Municipality/City/ Province
ODC Form 2A
O.R. SCRUB FORM
Major
Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA
Date Performed
and
Time Started
January 11, 3013
6:55 PM
Patients INITIALS (only)
Case Number
SURGICAL PROCEDURE
PERFORMED
C. S. D.
16-31-71
Explore Laparotomy +
Salphingectomy L
Noted by: ROMANOFF RAKI-IN, RN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364 Valid Until: March 17, 2016
September 21, 2015
Date document is signed: _______________ Time: __________________
_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____
O.R. Nurse on Duty
(Name and Signature)
Francis Padilla, RN
PRC Number: 0629394
Valid Until:
SUPERVISED BY
Clinical Instructor
Name and Signature
Nur-in D. Binudin, RN, MAN
PRC Number:
Valid Until:
Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D
(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Date document is signed: ______________
Time:
Please specify highest Nursing Degree Earned: Master of
MINDANAO STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: Lanao Del Norte Provincial Hospital
Hospital/Home/Lying-in, Municipality/City/Province
ODC Form 1C
CORD CARE FORM
Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA
Patients INITIALS (only)
Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)
Immediate Newborn Cord Care
PERFOMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home
D.R. Nurse on Duty
(Name and Signature)
(If Midwife on Duty, Signature
Not Required)
March 22, 2011
7:30 AM
Baby Boy A.
03-38-70
Cord Care
Neonatal Intensive Care Unit (NICU)
Vilma Alvia, RN
PRC Number:
Valid Until:
Julius Mirafuentes, RN, MN,
MAN
PRC Number: 0298656
Valid Until: November 2, 2015
February 01, 2012
2:15 AM
Baby Girl S.
03-38-48
Cord Care
Neonatal Intensive Care Unit (NICU)
Vilma Alvia, RN
PRC Number:
Valid Until:
Julius Mirafuentes, RN, MN,
MAN
PRC Number: 0298656
Valid Until:
Date Performed
and
Time Started
Noted by: ROMANOFF RAKI-IN, RN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Valid Until: March 17, 2016
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D
(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Date document is signed: _______________ Time: __________________
_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____
Date document is signed: ______________
Time:
Please specify highest Nursing Degree Earned: Master of
MINDANAO STATE UNIVERSITY
COLLEGE OF HEALTH SCIENCES
MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: AmaiPakpak Medical Center, Marawi City, Lanao del Sur
Hospital/Home/Lying-in, Municipality/City/Province
ODC Form 1C
CORD CARE FORM
Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA
Date Performed
and
Time Started
January 17, 2013
12:42 PM
Patients INITIALS (only)
Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)
Immediate Newborn Cord Care
PERFOMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home
D.R. Nurse on Duty
(Name and Signature)
(If Midwife on Duty, Signature
Not Required)
Baby Boy M.
14-16-95
Cord Care
Neonatal Intensive Care Unit (NICU)
Lovely Ann Olis, RN
PRC Number: 0723059
Valid Until:
Noted by: ROMANOFF RAKI-IN, RN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Valid Until: March 17, 2016
SUPERVISED BY
Clinical Instructor
Name and Signature
Shiennah O. Lunag
PRC Number: 0545623
Valid Until: March 13, 2015
Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D
(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Date document is signed: _______________ Time: __________________
_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____
Date document is signed: ______________
Time:
Please specify highest Nursing Degree Earned: Master of
