ODC Form 1

UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM

COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER, BATAC, ILOCOS NORTE
Hospital, Municipality/City/Province

(MAJOR OPERATIONS)

Prepared by:
Signature of
Name of Student RIOTOC, MARK ANGELO N. Student______________________________

O.R. Nurse On Supervised by

Date Performed and Patient’s Name PROCEDURE PERFORMED Duty (Name Clinical Instructor
Time Started
Case Number only) Name and Signature
VALENTINA MENDOZA,
SEPTEMBER 06, 2010 ELMER ESPEJO DEBRIDEMENT SKELETAL TRACTION RN
09:05 AM 100832 JOEL PE BENITO BATIN, RM, RN
SEPTEMBER 07, 2010 MADELYN CAMALIG EMERGENCY LOW SEGMENT CAESAREAN EVELYN GAJETON, RN
7:23 PM 593398 SECTION JOEL PE BENITO BATIN, RM, RN
SEPTEMBER 14, 2010 RHOWENA TADLAS TOTAL ABDOMINAL HYSTERECTOMY OSCAR SADORRA, RN
5:03 PM 593106 WITH BILATERAL SALPINGO-
OOPHORECTOMY JOEL PE BENITO BATIN, RM, RN

Noted by: VENERANDA L. QUICIO, RN Concurred by: MIRIAM R. RAMONES, RN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. ____________ Valid Until ____________________________
PNA No. __________ Valid Until _________________ PNA No. 5019 Valid Until ______LIFETIME___________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: __________________________________________

Approved by: LARGUITA P. REOTUTAR

(Print Name and
Signature)
 Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Republic of the Philippines

Republic of the Philippines ODC Form 1

UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN ABRA PROVINCIAL HOSPITAL, BANGUED, ABRA
Hospital, Municipality/City/Province

(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name only)
Case Number Name and Signature
NOVEMBER 29, 2010 RODRIGO BULDA APPLICATION OF ANTIMICROBIAL
11:23 AM 919791 BEADS, CALCANEUS RIGHT HAZELLE MENDOZA, R.N. HUSSEIN T. SIGANAY, RN, MAN

Noted by: VENERANDA L. QUICIO, RN Concurred by: KATHERINE F. CABUNOC, RN MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _____________ Valid Until _________________________
PNA No. __ Valid Until __________________________ PNA No. 9875 Valid Until ________LIFE MEMBER________________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR

(Print Name and
Signature)
 Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Republic of the Philippines ODC Form 1

UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN METRO VIGAN COOPERATIVE HOSPITAL, BANTAY, ILOCOS SUR
Hospital, Municipality/City/Province

(MAJOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name only)
Case Number Name and Signature
EXPLORATORY THORACOTOMY,
MARCH 25, 2011 MARK ALLEN VITE PERICARDIOTOMY AND JAROMY PSALM G. CARDENAS,
2:55 PM 11-0972 EVACUATION OF R.N. AUGUST GREGOR LAZO III, RM,RN
HEMOPERICARDIUM

Noted by: VENERANDA L. QUICIO, RN Concurred by: JOSEFINA AGAM, MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _____________ Valid Until __________________________
PNA No. Valid Until _________________________ PNA No. 18228 Valid Until _____________LIFE MEMBER__________________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 Approved by: LARGUITA P. REOTUTAR
(Print Name and
Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Republic of the Philippines

ODC Form 1
UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN SAINT JAMES HOSPITAL, VIGAN CITY, ILOCOS SUR
Hospital, Municipality/City/Province

(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name only)
Case Number Name and Signature
EXCISION OF BREAST MASS –
SEPTEMBER 03, 2009 TOMASA RACADIO RIGHT LOLITA QUINTUA, R.N
2:09 PM 09-1937 GERARD GABRIEL REOTUTAR, RM, RN, MAN

Noted by: VENERANDA L. QUICIO, RN Concurred by: SR. ASSUNTA M. PRADO, OSB, MAN
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. ________________ Valid Until ______________________
PNA No. _______ Valid Until ___________________ PNA No. 15709 Valid Until __________LIFE MEMBER_____________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR

(Print Name and
Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES ODC Form 1
COLLEGE OF HEALTH SCIENCES O.R. SCRUB FORM
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN GABRIELA SILANG GENERAL HOSPITAL, VIGAN CITY, ILOCOS SUR
Hospital, Municipality/City/Province

(MAJOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name only)
Case Number Name and Signature
APRIL 25, 2011 JENIFER PISCO OPEN REDUCTION INTERNAL ELVIE NAVARRO, RN HAZEL MAE RAGUNJAN, RN
12:15 PM 08030915 FIXATION – INTRAMEDULLARY
NAILING

Noted by: VENERANDA L. QUICIO, RN Concurred by: TERESITA F. AGATEP, MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _________________ Valid Until ____________________
PNA No. Valid Until _________________________ PNA No. __18229 Valid Until _________LIFE MEMBER_________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR

(Print Name and
Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS

Republic of the Philippines ODC Form 1

UNIVERSITY OF NORTHERN PHILIPPINES O.R. SCRUB FORM
COLLEGE OF HEALTH SCIENCES
Tamag, Vigan City, Ilocos Sur
Fax No. 722-2810

Accredited: PASUC, LEVEL III, YEAR GRANTED: 2004

SURGICAL SCRUB IN GABRIELA SILANG GENERAL HOSPITAL, VIGAN CITY, ILOCOS SUR
Hospital, Municipality/City/Province

(MINOR OPERATIONS)

Prepared by:
Name of Student RIOTOC, MARK ANGELO N. Signature of Student______________________________

Supervised by
Date Performed and Patient’s Name PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started PERFORMED (Name only)
Case Number Name and Signature
MARCH 25, 2011 EDGARDO ARELLANO HERNIORRHAPHY ELVIE NAVARRO, RN
12:15 PM 08030936 HAZEL MAE RAGUNJAN, RN
APRIL O1, 2011 BERNADETH MANIEGO COMPLETION CURETTAGE ELVIE NAVARRO, RN
10:03 AM 08028453 HAZEL MAE RAGUNJAN, RN
APRIL 01, 2011 ALMER PINTOR REMOVAL OF IMPLANT ELVIE NAVARRO, RN
01:28 PM 08023844 RIGHT TIBIA HAZEL MAE RAGUNJAN, RN

Noted by: VENERANDA L. QUICIO, RN Concurred by: TERESITA F. AGATEP, MAN

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0072470 Valid Until NOVEMBER 14, 2012 Chief Nurse, PRC I.D. No. _________________ Valid Until ____________________
PNA No. Valid Until _________________________ PNA No. __18229 Valid Until _________LIFE MEMBER_________
Date Document Is Signed:______________________ Time ________________________ Date Document Is Signed:_________________________ Time _____________________
Highest Nursing Degree Earned: MASTER OF ARTS IN TEACHING HEALTH EDUCATION Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING

Approved by: LARGUITA P. REOTUTAR

(Print Name and
Signature)
Dean, PRC No. 0078616 Valid Until AUGUST 8, 2012 PNA No. 14314 Valid Until LIFETIME
ADPCN No. 0100 Valid Until DECEMBER 2013 Date Document Is Signed: _______________ Time ____________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING