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: cn@wmsu.edu.ph / 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: cn@wmsu.edu.ph / 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: cn@wmsu.edu.ph / 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: cn@wmsu.edu.ph / 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