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College of Nursing: Sotejo Hall, Pedro Gil ST., Ermita, Manila

This document contains forms from the University of the Philippines Manila College of Nursing for students to document their surgical scrub and circulating experiences in the operating room. The forms include spaces for the student's name and signature, date and time, patient initials, surgical procedure, supervising nurse and instructor. Signatures are also required from the clinical coordinator, chief nurse, and dean to approve the student's documentation. There are separate forms for scrubbing (Form 1A and 1B) and circulating (Form 2A).

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Geneva Latorre
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123 views3 pages

College of Nursing: Sotejo Hall, Pedro Gil ST., Ermita, Manila

This document contains forms from the University of the Philippines Manila College of Nursing for students to document their surgical scrub and circulating experiences in the operating room. The forms include spaces for the student's name and signature, date and time, patient initials, surgical procedure, supervising nurse and instructor. Signatures are also required from the clinical coordinator, chief nurse, and dean to approve the student's documentation. There are separate forms for scrubbing (Form 1A and 1B) and circulating (Form 2A).

Uploaded by

Geneva Latorre
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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University of the Philippines Manila

The Health Sciences Center


COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: [email protected]
Website: http://cn.upm.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

Date Performed
and
Time Started
Patients INITIALS (only)
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number






(STRICTLY NO DESIGNATES)
[These Forms must be printed at the back of the 1
st
page of the Competency-Based Performance Evaluation Checklist prescribed by the BON]




Noted by: ARNOLD B. PERALTA, BSN, MAN, MHPeD
(Print Name and Signature)
Clinical Coordinator, N-105
PRC ID NO. __________ Valid Until ____________
Date Signed: _________________ Time: ________

Noted by:
(Print Name and Signature)
Chief Nurse
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

Approved by: LOURDES MARIE S. TEJERO, RN, MAN, PhD
(Print Name and Signature)
Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

O.R. Form 1A
O.R. SCRUB FORM
Major

University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: [email protected]
Website: http://cn.upm.edu.ph


SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

Date Performed
and
Time Started
Patients INITIALS (only)
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number






(STRICTLY NO DESIGNATES)
[These Forms must be printed at the back of the 1
st
page of the Competency-Based Performance Evaluation Checklist prescribed by the BON]
O.R. Form 1B
O.R. CIRCULATING
FORM
University of the Philippines Manila
The Health Sciences Center
COLLEGE OF NURSING
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel. # 523-14-77 Telefax # 523-14-85
Email: [email protected]
Website: http://cn.upm.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

Date Performed
and
Time Started
Patients INITIALS (only)
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature Case Number







Noted by: ARNOLD B. PERALTA, BSN, MAN, MHPeD
(Print Name and Signature)
Clinical Coordinator, N-105
PRC ID NO. __________ Valid Until ___________
Date Signed: _______________ Time: ______

Noted by:
(Print Name and Signature)
Chief Nurse, Dr. Jose Fabella Memorial Hospital
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________

Approved by: LOURDES MARIE S. TEJERO, RN, MAN, PhD
(Print Name and Signature)
Dean, UP College of Nursing
PRC ID NO. __________ Valid Until _________________
Date Signed: ___________________ Time: ____________


(STRICTLY NO DESIGNATES)

ODC Form 2A
O.R. SCRUB FORM
Major

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