900, , Ermita, 1000

Telefax (632) 536-20-99, Website: www.adamson.edu.ph

Accredited by: Commission on Higher Education, Government Recognition No. 013, February 5, 2007
ACTUAL DELIVERY in OSPITAL NG SAMPALOC

ODC Form IA
ACTUAL DELIVERY
FORM

Prepared by: Fua, Sean Harvey S.

Patients Name
SUPERVISED BY
Date Performed
D.R. Nurse On Duty

Clinical
Instructor
PROCEDURE
and
(Name and Signature)
Noted
Name
and
Signature

Time Started
(If Midwife on Duty, Signature
PERFORMED
by:

not
Case Number
Required)

January 27, 2015

Dote, Juvelle C.
Normal Spontaneous Delivery
Liezel R. Velasco, RN
Minerva P. Raguini, RN, RM,

7:21 AM
704309
MaEd.S

Approved by:

JOY G. PALOMAREZ-DELEN, Ed.D., MAN, RN

NARESSIA SELUDO
BALLENA, EdD., MAN, RN
Clinical Coordinator
Dean

PRC I. D. No.:____0264861____ Valid Until: ___07-11-2014__

PRC I.D. No.: __0196534___ Valid Until: ___10
04-2014____

Date document is signed: __________ Time: __________

Date Document is signed: _____________

Time: ________

Highest Nursing Degree Earned: Doctor of Education

Highest Nursing Degree Earned: ___Doctor of

Education___

ADAMSON UNIVERSITY
College of Nursing
900, , Ermita, 1000
Telefax (632) 536-20-99, Website: www.adamson.edu.ph
Accredited by: Commission on Higher Education, Government Recognition No. 013, February 5, 2007
Immediate Newborn Cord Care in OSPITAL NG SAMPALOC

Prepared by: Fua, Sean Harvey S.

Patients
Name

Date Performed
Immediate Newborn
and

Case Number
Time Started
(not applicable for

Cord Care PERFORMED

Birthing/Lying-in

Clinics/Homes)
Indicate where performed

e.g.

D.R., Nursery, NICU,

or

Home

January 28,
Baby Girl Zonio
Nursery

2015
069304

10:14 AM

Approved by:

JOY G. PALOMAREZ-DELEN, EdD, MAN, RN

BALLENA, EdD, MAN, RN

Clinical Coordinator

Dean

PRC I. D. No.:____0264861____ Valid Until: ___07-11-2014__

Nursery Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
signature not required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Liezel R. Velasco

Minerva P. Raguini, RN, RM,

MaEd.S

NARESSIA

Noted
by:

SELUDO-

PRC I.D. No.: __0196534___ Valid Until: ___10-

900, , Ermita, 1000

04-2014____
Telefax (632) 536-20-99, Website: www.adamson.edu.ph
Date document is signed: __________ Time: __________
Date Document is signed: _____________
Accredited by: Commission on Higher Education, Government Recognition No. 013, February 5, 2007
Time: ________
ACTUAL DELIVERY in GAT ANDRES BONIFACIO MEMORIAL MEDICAL CENTER
Highest Nursing Degree Earned: Doctor of Education
Highest Nursing Degree Earned: ___Doctor of
Education___
Prepared by: Fua, Sean Harvey S.

ODC Form IA
ACTUAL DELIVERY

FORM

Patients Name
SUPERVISED BY
Date Performed
D.R. Nurse On Duty

Clinical
Instructor
PROCEDURE
and
(Name and Signature)
Noted
Name
and
Signature
Time Started
(If Midwife on Duty, Signature
PERFORMED

by:
not
Case Number

Required)

March 2, 2015
Costanilla, Mercedita
Normal Spontaneous Delivery
Janette B. Umali, RN
Niela S. Rosales, RN, MAN

3:20 AM
151516

Approved
by:

JOY G. PALOMAREZ-DELEN, Ed.D., MAN, RN

NARESSIA SELUDO
BALLENA, EdD., MAN, RN

Clinical Coordinator
Dean

PRC I. D. No.:____0264861____ Valid Until: ___07-11-2014__

PRC I.D. No.: __0196534___ Valid Until: ___10
04-2014____

Date document is signed: __________ Time: __________

Date Document is signed: _____________

Time: ________

900, , Ermita, 1000

Highest Nursing Degree Earned: Doctor of Education

Highest Nursing Degree Earned: ___Doctor of
Telefax (632) 536-20-99, Website: www.adamson.edu.ph
Education___
Accredited by: Commission on Higher Education, Government Recognition No. 013, February 5, 2007
ACTUAL DELIVERY in OSPITAL NG SAMPALOC
Prepared by: Fua, Sean Harvey S.

ODC Form IA

ACTUAL DELIVERY

FORM

Patients Name
SUPERVISED BY
Date Performed
D.R. Nurse On Duty

Clinical
Instructor
PROCEDURE
and
(Name and Signature)
Noted

Name
and
Signature
Time Started
(If Midwife on Duty, Signature
PERFORMED
by:

not
Case Number
Required)

March 3, 2015
Bacolod, Liezyl-lyn
Normal Spontaneous Delivery
Astrofel Pimentel, RN
Niela S. Rosales, RN, MAN

1:45 AM
151543

Approved by:

JOY G. PALOMAREZ-DELEN, Ed.D., MAN, RN

NARESSIA SELUDO
BALLENA, EdD., MAN, RN

Clinical Coordinator
Dean

PRC I. D. No.:____0264861____ Valid Until: ___07-11-2014__

PRC I.D. No.: __0196534___ Valid Until: ___1004-2014____

Date document is signed: __________ Time: __________

Date Document is signed: _____________

Time: ________
Highest Nursing Degree Earned: Doctor of Education
Education___

Highest Nursing Degree Earned: ___Doctor of