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TRACE COLLEGE

El Danda Street, Batong Malake, Los Baños, Laguna


Telephone no. (049) 536-3944, Fax (049) 536-1425, Web-Site www.tracecollege.edu.ph
SURGICAL SCRUB in ____________________________________________________________________________________
Hospital, Municipality/City/Province

O.R. Form 1A
Prepared by: O.R. SCRUB FORM
Major
Printed Name with Signature of Student: _____________________________________________

Date Performed Patient’s INITIALS only O.R. Nurse on Duty SUPERVISED BY


and SURGICAL (Name AND Signature) Clinical Instructor
Time Started Case Number PROCEDURE Name and Signature
PERFORMED

O.R. Form 1B
Prepared by: O.R. CIRCULATING
FORM
Printed Name with Signature of Student: _____________________________________________

Date Performed Patient’s INITIALS only O.R. Nurse on Duty SUPERVISED BY


and SURGICAL (Name AND Signature) Clinical Instructor
Time Started Case Number PROCEDURE Name and Signature
PERFORMED

(STRICTLY NO DESIGNATES)
D

TRACE COLLEGE
El Danda Street, Batong Malake, Los Baños, Laguna
Telephone no. (049) 536-3944, Fax (049) 536-1425, Web-Site www.tracecollege.edu.ph
ACTUAL DELIVERY in ____________________________________________________________________________________
Hospital/ Home/ Lying-In Clinic, Municipality/City/Province
D.R. Form
Prepared by:
Printed Name with Signature of Student: _____________________________________________ ACTUAL DELIVERY Form

Date Performed Patient’s INITIALS only


and D.R. Nurse on Duty SUPERVISED BY
PROCEDURE
Time Started Case Number (Name AND Clinical Instructor
PERFORMED Signature) Name and Signature
(not applicable for
Birthing/Lying-In Clinics/Homes)

IMMEDIATE NEWBORN CORD CARE in ____________________________________________________________________


Hospital/ Home/ Lying-In Clinic, Municipality/City/Province

Prepared by: ICNB Form


IMMEDIATE CARE OF
Printed Name with Signature of Student: _____________________________________________ THE NEWBORN FORM

Date Performed Patient’s INITIALS only


and Immediate Newborn SUPERVISED BY
O.R. Nurse on Duty
Time Started Case Number Cord Care (Name AND Signature)
Clinical Instructor
(not applicable for PERFORMED Name and Signature
Birthing/Lying-In Clinics/Homes)

(STRICTLY NO DESIGNATES)