ODC Form 1A

ACTUAL DELIVERY
FORM
UNIVERSITY OF SAN AGUSTIN
GENERAL LUNA STREET, ILOILO CITY
Tel. No.: (033)337-48-41 to 44 Local 259, Fax No.: (033)337-44-03, E-mail Address: cn@usa.edu.ph, Web-Site: www.usa.edu.ph

ACTUAL DELIVERY in Aleosan District Hospital, Alimodian, Iloilo

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student PERLAS, Suzette Padasas

Date Performed Patient’s INITIAL Only Procedure Performed D.R. Nurse on Duty SUPERVISED BY
and ____________________________ (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Signature Not Name and Signature
(not applicable for Birthing/Lying-In Clinics/Homes) Required)

16-February-11
A.P. Normal Spontaneous Vaginal Delivery Cecilia Alegrado, R.N. Rosadel Faceronda, R.N.
7:55 AM
059355

Noted: _Lorna V. Badian, R.N.,M.A.N. ______ Approved by: _Sofia Cosette P. Monteblanco, R.N.,M.A.N. ___________________
(Printed Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0110465 Valid Until October 29, 2013 Dean, PRC I.D. No. 0042682 Valid Until February 1, 2013
Date document is signed: __________________ Time ______________________ Date document is signed: ________________________ Time ____________________________
Please specify Highest Nursing Degree Earned: M.A.N _____________________ Please specify Highest Nursing Degree Earned: M.A.N._________________________________
ODC Form 1B
ASSISTED DELIVERY
FORM
 ODC Form 1C
CORD CARE FORM

UNIVERSITY OF SAN AGUSTIN

GENERAL LUNA STREET, ILOILO CITY
Tel. No.: (033)337-48-41 to 44 Local 259, Fax No.: (033)337-44-03, E-mail Address: cn@usa.edu.ph, Web-Site: www.usa.edu.ph

IMMEDIATE NEWBORN CORD CARE in Aleosan District Hospital, Alimodian, Iloilo

Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student PERLAS, Suzette Padasas

Date Performed Patient’s INITIAL Only Immediate Newborn Cord Care D.R. Nurse on Duty SUPERVISED BY
and ____________________________ PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (If Midwife on Duty, Signature Not Name and Signature
(not applicable for Birthing/Lying-In Clinics/Homes) Indicate where performed e.g. D.R., Nursery, Required)
NICU, or Home

16-February-11
Bb. B. S. Delivery Room Cecilia Alerado, R.N. Rosadel Faceronda, R.N.
10:24 AM 059392

Noted: _Lorna V. Badian, R.N.,M.A.N. _______ Approved by: _Sofia Cosette P. Monteblanco, R.N.,M.A.N. ___________________
(Printed Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0110465 Valid Until October 29, 2013 Dean, PRC I.D. No. 0042682 Valid Until February 1, 2013
Date document is signed: __________________ Time ______________________ Date document is signed: ________________________ Time ____________________________
Please specify Highest Nursing Degree Earned: M.A.N _____________________ Please specify Highest Nursing Degree Earned: M.A.N._________________________________