Assisted UoPCN Case Slip

21
UNIVERSITY OF PANGASINAN Name of Patient: Name of Patient:

PHINMA Education Network ____________________________________________________ ____________________________________________________
College of Nursing Address: _____________________________________________ Address: ____________________________________________
Dagupan City Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________
Gravida: ______________ Para: __________________________ Gravida: ______________ Para: _________________________
ASSISTED CASE SLIP Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Time of Delivery: _____________________________________ Time of Delivery: _____________________________________
Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Name of Student Diagnosis: ___________________________________________ Diagnosis: __________________________________________
____________________________________________________ ____________________________________________________
___________________________ ____________________________________________________ ____________________________________________________
Student Number Obstetrician: _________________________________________ Obstetrician: _________________________________________
_________________________ _____________________ _________________________ _____________________

PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
Clinical Coordinator
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________
PRC NO: 0133422 VALID UNTIL: July 27, 2011 .
PNA NO: .VALID UNTIL: . Agency: Agency:
ANSAP NO: .VALID UNTIL: . ____________________________________________________ ____________________________________________________
354
Name of Patient: Name of Patient: Name of Patient:
____________________________________________________ ____________________________________________________ ____________________________________________________
Address: ____________________________________________ Address: _____________________________________________ Address: ____________________________________________
Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________ Age: _________________ Case No: ______________________
Gravida: ______________ Para: _________________________ Gravida: ______________ Para: __________________________ Gravida: ______________ Para: _________________________
Date of Delivery: _____________________________________ Date of Delivery: ______________________________________ Date of Delivery: _____________________________________
Gender of Baby: ______________________________________ Gender of Baby: _______________________________________ Gender of Baby: ______________________________________
Time of Delivery: _____________________________________ Time of Delivery: _____________________________________ Time of Delivery: _____________________________________
Type of Delivery: _____________________________________ Type of Delivery: ______________________________________ Type of Delivery: _____________________________________
Diagnosis: __________________________________________ Diagnosis: ___________________________________________ Diagnosis: __________________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
____________________________________________________ ____________________________________________________ ____________________________________________________
Obstetrician: _________________________________________ Obstetrician: _________________________________________ Obstetrician: _________________________________________
_________________________ _____________________ _________________________ _____________________ _________________________ _____________________

Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor Staff Nurse on Duty Nurse Instructor
PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________ PRC No. __________ PRC No. ___________
Agency: Agency: Agency:

____________________________________________________ ____________________________________________________ ____________________________________________________

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21

UNIVERSITY OF PANGASINAN Name of Patient: Name of Patient:

_______________ _ _ _______

_______________ _ _____ _ _ _______

Agency: Agency: Agency:

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