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ACTUAL DELIVERY
FORM
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
ACTUAL DELIVERY in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
Patients INITIALS(only)
Date Performed
and
Time Started
PROCEDURE
PERFORMED
December 12,2015
(4:40 PM)
Case Number
(not applicable for
Birthing/Lying-in
Clinics/Homes)
LML
255782
MA
260661
RLT
265606
JUDITH DENILA,RN,MAN
PRC
MERLITA OMLERO,RN
PRC 0101442
JUDITH DENILA,RN,MAN
PRC
SUPERVISED BY
Clinical Instructor
Name and Signature
Noted by:
Approved by:
ODC Form 1B
ASSISTED
Mindanao State University-Iligan Institute of Technology
Andres Bonifacio Avenue, Tibanga, Iligan City
063-2210744/www.msuiit.edu.ph
Level 2 Status (Sept. 1, 2013 Aug. 31, 2016)
by the Accrediting Agency of Chartered Colleges and University
in the Philippines, Inc. (AACUP)
DELIVERY FORM
ACTUAL DELIVERY in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
Patients INITIALS(only)
Date Performed
and
Time Started
PROCEDURE
PERFORMED
December 9, 2015
(8:10 PM)
Case Number
(not applicable for
Birthing/Lying-in
Clinics/Homes)
CAM
255352
MN
256659
April,16,2016
(5:10 PM)
KKC
268146
SUPERVISED BY
Clinical Instructor
Name and Signatusre
LYNUEL R. SANTILLANA,RN,MAN
PRC 0382115
GLORIA SHIELA COYOCA,RN,MAN
PRC 0256493
CARMELA D. ORTEGA,RN,MAN
PRC 0390177
Noted by:
Approved by:
ODC Form 1C
CORD CARE FORM
IMMEDIATE NEWBORN CORD CARE in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
Patients INITIALS(only)
Date Performed
and
Time Started
Case Number
(not applicable for Birthing/Lyingin Clinics/Homes)
()
Bb Girl N
255651
()
Bb Girl G
256683
()
Bb Boy D
271525
Nurse On Duty
(Name and Signature)
(If midwife on duty,
Signature Not Required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Noted by:
Approved by:
ODC Form 2A
O.R. SCRUB
FORM Major
SURGICAL SCRUB in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
Patients INITIALS(only)
Date Performed
and
Time Started
SURGICAL PROCEDURE
PERFORMED
Case Number
SUPERVISED BY
Clinical Instructor
Name and Signature
Noted by:
Approved by:
ODC Form 2B
O.R. CIRCULATING
FORM
SURGICAL SCRUB in GREGORIO T. LLUCH MEMORIAL HOSPITAL, Iligan City, Lanao del Norte
Date Performed
and
Time Started
Patients
INITIALS(only)
Case Number
SURGICAL
PROCEDURE
PERFORMED
SUPERVISED BY
Clinical Instructor
Name and Signature
Noted by:
Approved by: