PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA)

General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

SURGICAL SCRUB in UNIVERSITY OF THE PHILIPPINES PHILIPPINE GENERAL HOSPITAL
Hospital, Municipality/City/ Province
Prepared by:
Printed Name with Signature of Student FABROS, DANIEL VINCENT E.

Date Performed
and
Time Started
Patient's INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
(Name and Signature)
Case Number
November 25, 2013-
6:02 PM


LD
3966448

Inferomedial Maxillectomy, Left



David Paul R. Ramos, RN, MAN

November 25, 2013
9:45 AM


KJM
3984748

Open Reduction Internal Fixation Using Titanium Plates
And Screws With Intermandibulo-Maxillary
Fixation


David Paul R. Ramos, RN, MAN

November 25, 2013
12:00 NN

LV
3855249

Excission via Lateral Rhinotomy


David Paul R. Ramos, RN, MAN


November 25, 2013
9:53 PM

CF
2654893

CTURP, Cystolithotomy


David Paul R. Ramos, RN, MAN


November 25, 2013
12:20 PM


EBC
3463661

Below Knee Amputation, Right


David Paul R. Ramos, RN, MAN








Noted by: JOAN M. OYANGOREN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0422859 Valid Until December 12, 2016
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Science in Nursing
Approved by: DR. GILMORE G. SOLIDUM
(Print Name and Signature)
Dean, PRC I.D. No. 0172020 Valid Until July 27, 2014
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: PhD
ODC Form 2A
O.R. SCRUB FORM
MAJOR
PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

SURGICAL SCRUB in JOSE REYES MEMORIAL MEDICAL CENTER
Hospital, Municipality/City/ Province
Prepared by:
Printed Name with Signature of Student FABROS, DANIEL VINCENT E.

Date Performed
and
Time Started
Patient's INITIALS (only)
SURGICAL PROCEDURE PERFORMED
O.R Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
(Name and Signature)
Case Number
January 6, 2014
5:30 PM

JHG
919717 Wound Debridement and Suturing Joan B. Yumul RN Benjamin I. Tablizo Jr. RN, MAN
January 6, 2014
6:21 PM

AA
919723 Wound Debridement and Suturing Joan B. Yumul RN Benjamin I. Tablizo Jr. RN, MAN
January 6, 2014
8:20 PM

CR
919666 Left Foot, Incision and Drainage Joan B. Yumul RN Benjamin I. Tablizo Jr. RN, MAN
January 7, 2014
9:20 PM

MJD
920168 Wound Exploration: Foreign Body Extraction and Suturing Joan B. Yumul RN Benjamin I. Tablizo Jr. RN, MAN
January 7, 2014
6:00 PM

AIC
920038 Completion Aputation, Right Small Finger Joan B. Yumul RN Benjamin I. Tablizo Jr. RN, MAN







Noted by: JOAN M. OYANGOREN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0422859 Valid Until December 12, 2016
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Science in Nursing
Approved by: DR. GILMORE G. SOLIDUM
(Print Name and Signature)
Dean, PRC I.D. No. 0172020 Valid Until July 27, 2014
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: PhD
ODC Form 2A
O.R. SCRUB FORM
MAJOR
ODC Form 2B
O.R. MINOR FORM
PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

ACTUAL DELIVERY in OSPITAL NG MAYNILA MEDICAL CENTER, MANILA
Hospital, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student FABROS, DANIEL VINCENT E.

Date Performed
and
Time Started
Patient's INITIALS (only)
PROCEDURE PERFORMED
D.R. Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not Required)
SUPERVISED BY
Clinical Instructor
(Name and Signature)
Case Number
(not applicable for Birthing/Lying-In
Clinics/Homes)
September 2, 2013
6:20 PM

IJTV
2627650
Gravida 4 Parity 2, 40 4/7 Weeks of Age of
Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Christian Marie Apolo RN
Janet E. Lacsa, RN, RM, MAN
September 3, 2013
2:45 PM
RGP
1606359
Gravida 2 Parity 1, 38 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Tessa Jane H. Metran RN
Janet E. Lacsa, RN, RM, MAN
September 9, 2013
7:10 PM
JSL
1720623
Gravida 6 Parity 5, 39 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Elaine Garcia RN
Janet E. Lacsa, RN, RM, MAN
June 3, 2013
8:44 PM
KD
2597085
Gravida 1 Parity 0, 38 5/7 Weeks of Age of
Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Tessa Jane H. Metran RN
Janet E. Lacsa, RN, RM, MAN
September 21, 2012
6:16 PM
JSN
1702010
Gravida 8 Parity 7, 41 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Maria Antonete Ramil RN
Janet E. Lacsa, RN, RM, MAN





Noted by: JOAN M. OYANGOREN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.

Valid Until
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
Approved by: DR. GILMORE G. SOLIDUM
(Print Name and Signature)
Dean, PRC I.D. No. 0172020 Valid Until
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: PhD
ODC Form 2A
O.R. SCRUB FORM
MAJOR
ODC Form 1A
ACTUAL DELIVERY FORM

PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

ASSISTED DELIVERY in OSPITAL NG MAYNILA MEDICAL CENTER, MANILA
Hospital, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student FABROS, DANIEL VINCENT E.

Date Performed
and
Time Started
Patient's INITIALS (only)
PROCEDURE PERFORMED
ASSISTED DELIVERY
D.R. Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature Not Required)
SUPERVISED BY
Clinical Instructor
(Name and Signature)
Case Number
(not applicable for Birthing/Lying-In
Clinics/Homes)
June 18, 2013
2:40 PM
JAP
2601465
Gravida 2 Parity 1, 39 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Tessa Jane H. Metran RN
Janet E. Lacsa, RN, RM, MAN
July 9, 2013
7:44 PM
SMAH
2603805
Gravida 1 Parity 0, 411/7 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Myra Dela Cruz RN
Janet E. Lacsa, RN, RM, MAN
July 15, 2013
7:22 PM
MG
2609863
Gravida 2 Parity 1, 38 5/7 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Myra Dela Cruz RN
Janet E. Lacsa, RN, RM, MAN
July 15, 2013
8:25 PM
MBM
2609870
Gravida 3 Parity 2, 375/7 Weeks of Age of Gestation,
Prenancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Tessa Jane H. Metran RN
Janet E. Lacsa, RN, RM, MAN
July 22, 2013
5:25 PM
LR
2613357
Gravida 4 Parity 3, 40 Weeks of Age of Gestation,
Pregnancy Uterine, Cephalic in Labor
Normal Spontaneous Delivery Myra A. Ramil RN
Janet E. Lacsa, RN, RM, MAN





Noted by: JOAN M. OYANGOREN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.

Valid Until
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
Approved by: DR. GILMORE G. SOLIDUM
(Print Name and Signature)
Dean, PRC I.D. No. 0172020 Valid Until
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: PhD
ODC Form 2A
O.R. SCRUB FORM
MAJOR
ODC Form 1B
ASSISTED DELIVERY
FORM



PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA)
General Luna St. corner Muralla St., Manila, Philippines, 1002
Telephone No. (+632) 527 7941
Web Address: www.plm.edu.ph

IMMEDIATE NEWBORN CORD CARE in
Hospital, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student FABROS, DANIEL VINCENT E.

Date Performed
and
Time Started
Patient's INITIALS (only)
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 Not Required)
SUPERVISED BY
Clinical Instructor
(Name and Signature)
Case Number
(not applicable for Birthing/Lying-In
Clinics/Homes)

















Noted by: JOAN M. OYANGOREN
(Print Name and Signature)
Clinical Coordinator, PRC I.D. No. Valid Until
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: Master of Arts In Nursing
Approved by: DR. GILMORE G. SOLIDUM
(Print Name and Signature)
Dean, PRC I.D. No. 0172020 Valid Until
Date document is signed:

Time
Please specify Highest Nursing Degree Earned: PhD
ODC Form 2A
O.R. SCRUB FORM
MAJOR
ODC Form 1C
CORD CARE FORM