WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines ODC Form 2A

O.R. SCRUB FORM
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph Major
Accredited by: Accrediting Agency of Chartered Colleges and Universities in the Philippines (AACCUP)
/ Level II Re-accredited / February 2009
SURGICAL SCRUB in Western Mindanao Medical Center, Zamboanga City
Hospital, Municipality / City / Province

Prepared by:
Printed Name with Signature of Student: OLIVO, JONEJAY UBUNGEN

Date Performed Patient’s INITIALS (only) SUPERVISED BY:

SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

March 06, 2010 E. A. Primary Low Cervical

Transverse Cesarean Section Katrina Concepcion Pinga, R.N. Sharon P. Pacaldo, R.N.
05:43 P.M. 020820 Extracted Live Twin Baby Girls

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
WESTERN MINDANAO STATE UNIVERSITY
ODC Form 2B
MINOR FORM
 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 Zamboanga City Medical Center, Zamboanga City
Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: OLIVO, JONEJAY UBUNGEN

Date Performed Patient’s INITIALS (only) SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY:
and (Name and Signature) Clinical Instructor
Case Number PERFORMED
Time Started Name and Signature

November 17, 2009 V. F

Fractional Dilation and Curettage Lloela D. Mariano, R.N. Agnes Riela Castillo, R.N.
10:56 A.M. 269406

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
WESTERN MINDANAO STATE UNIVERSITY
ODC Form 1A
ACTUAL DELIVERY FORM
 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 Zamboanga City Medical Center, Zamboanga City
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: OLIVO, JONEJAY UBUNGEN

Patient’s INITIALS (only) D.R. Nurse On Duty

Date Performed SUPERVISED BY:
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Case Number
(If Midwife on Duty,
Time Started (not applicable for Birthing /Lying
Signature is not Required)
Name and Signature
–In Clinics / Homes)

November 18, 2009 M. C. P. S.

Normal Spontaneous Vaginal Delivery Joy Del Rio, R.M. Agnes Riela Castillo, R.N.
11: 29 A.M. 256559

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing
WESTERN MINDANAO STATE UNIVERSITY
Normal Road, Baliwasan, Zamboanga City, Philippines ODC Form 1B
ASSISTED DELIVERY
FORM
 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 Zamboanga City Medical Center, Zamboanga City
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: OLIVO, JONEJAY UBUNGEN

Patient’s INITIALS (only) D.R. Nurse On Duty

Date Performed PROCEDURE PERFORMED SUPERVISED BY:
and (Name and Signature) Clinical Instructor
Case Number
(If Midwife on Duty,
Time Started (not applicable for Birthing /Lying – ASSISTED DELIVERY Signature is not Required)
Name and Signature
In Clinics / Homes)

November 16, 2009 M. A. Normal Spontaneous Vaginal Delivery Lloela D. Mariano, R.N. Agnes Riela Castillo, R.N.

12: 40 P.M. 269608

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing

WESTERN MINDANAO STATE UNIVERSITY

Normal Road, Baliwasan, Zamboanga City, Philippines ODC Form 1C
CORD CARE FORM
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
IMMEDIATE NEWBORN CORD CARE in Zamboanga City Medical Center, Zamboanga City
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: OLIVO, JONEJAY UBUNGEN

Patient’s INITIALS (only) Immediate Newborn Cord D.R. Nurse On Duty

Date Performed SUPERVISED BY:
and Case Number Care PERFORMED (Name and Signature) Clinical Instructor
Indicate where performed e.g. (If Midwife on Duty,
Time Started (not applicable for Birthing /Lying –
Signature is not Required)
Name and Signature
In Clinics / Homes) D.R., Nursery, NICU, or Home

November 18, 2009 Baby Boy E.

Delivery Room Eleanor F. Arcillas, R.M., R.N. Agnes Riela Castillo, R.N.
10:36 A.M. 272307

November 18, 2009 Baby Boy R.

Delivery Room Eleanor F. Arcillas, R.M., R.N. Agnes Riela Castillo, R.N.
10:50 A.M. 116578

Noted by: SARAH S. TAUPAN, R.N., M.N. Approved by: GLORIA G. FLORENDO, R.N., M.N., Ph.D.
Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2012 Dean, PRC I.D. No. 0054293 Valid Until: January 3, 2013
Date document is signed: Time: Date document is signed: Time:
Please specify Highest Nursing Degree Earned: Master in Nursing Specify Highest Nursing Degree Earned: Master in Nursing