PRC Form

OUR LADY OF FATIMA UNIVERSITY #1 Esperanza St.
Hilltop Mansion Heights, Lagro, Quezon City
Name of Student: AGARPAO, HONEYLYN ESTRELLA _________________________________________________________________________________________________________________________ Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, #1 ESPERANZA ST. HILLTOP MANSION HEIGHTS, LAGRO, QUEZON CITY Accreditation Level (if any): PACUCOA LEVEL II_____________________Year Granted: APRIL 10.2002 Date School/Program was Recognized: APRIL 15, 2001 _ Number: 033 _ Year: 2011 First Course (if any) : NOT APPLICABLE _ School Graduated From: NOT APPLICABLE _ Year: NOT APPLICABLE ________________________________________________ Year of Admission in the Bachelor of Science in Nursing Program: JUNE 2008 Year Graduated (BSN Program): OCTOBER 2010
No. 1. 2. 3. 4. 5. Date of Operation Case No. Name of Patient Diagnosis I. Major Operations Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Supervised by Qualified CI Signature of Qualified CI
Prepared by: AGARPAO,HONEYLYN E. Signature over printed Name of Student Supervised by: CECILE F. GUEVARRA RN, MAN Signature over printed name of Faculty Date Signed: ____________ Degree: BSN, MAN a.) PRC NO: 293775 Valid Until: March 13, 2013 b.) PNA NO: 18471
Valid Until: Lifetime Noted by: Concurred by: LIZA MAY B. JECINO RN, MAN Signature over printed name of Clinical Coordinator Date Signed: _________ Degree: BSN, MAN b.) PRC NO: 164056 Valid Until: January 25, 2013 b.) PNA NO: 2011-17397 Valid Until: Lifetime ARLENE GALANG-GENEROSA, RN, MAN Signature over printed name of Chief Nurse Date Signed: ___________ Degree: BSN, MAN a.) PRC NO:152240 Valid Until: October 19, 2014 b.) PNA NO: 18248
Valid Until: Lifetime Approved by: NELIA R. CAPULONG, RN, MAN Signature over printed name of Dean Date Signed: ____________ Degree: BSN, MAN a.) PRC NO: 0041904 Valid Until: July 31, 2012 b.) PNA NO: 18698 Valid Until: Lifetime
c.) ADPCN NO: 0627
Valid Until: December 2010
OUR LADY OF FATIMA UNIVERSITY #1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City
No. 1. 2. 3. 4. 5. Date of Operation Case No. Name of Patient Diagnosis II. Minor Operations Operation Type of Performed Anesthesia Name of Surgeon Name of Hospital Supervised by Qualified CI Signature of Qualified CI
Prepared by: AGARPAO,HONEYLYN E. Signature over printed Name of Student Supervised by: CECILE F. GUEVARRA RN, MAN Signature over printed name of Faculty Date Signed: ____________ Degree: BSN, MAN c.) PRC NO: 293775 Valid Until: March 13, 2013
b.) PNA NO: 18471 Valid Until: Lifetime Noted by: LIZA MAY B. JECINO RN, MAN Signature over printed name of Clinical Coordinator Date Signed: _________ Degree: BSN, MAN d.) PRC NO: 164056 Valid Until: January 25, 2013 b.) PNA NO: 2011-17397
Valid Until: Lifetime
Concurred by: ARLENE GALANG-GENEROSA, RN, MAN Signature over printed name of Chief Nurse Date Signed: ___________ Degree: BSN, MAN
b.) PRC NO:152240 Valid Until: October 19, 2014 b.) PNA NO: 18248 Valid Until: Lifetime Approved by: NELIA R. CAPULONG, RN, MAN Signature over printed name of Dean Date Signed: ____________ Degree: BSN, MAN
b.) PRC NO: 0041904
Valid Until: July 31, 2012 b.) PNA NO: 18698
Valid Until: Lifetime c.) ADPCN NO: 0627
Valid Until: December 2010
No. 1. 2. 3. 4. 5. Case No. Diagnosis Name of Mother Age III. Actual Deliveries Date of Time of Delivery Delivery Gender of Baby Name of Hospital Type of Delivery Supervised by: Signature of Qualified C.I.
Prepared by: AGARPAO,HONEYLYN E. Signature over printed Name of Student Supervised by: CECILE F. GUEVARRA RN, MAN
Signature over printed name of Faculty Date Signed: ____________ Degree: BSN, MAN e.) PRC NO: 293775 Valid Until: March 13, 2013 b.) PNA NO: 18471 Valid Until: Lifetime Noted by:
LIZA MAY B. JECINO RN, MAN Signature over printed name of Clinical Coordinator Date Signed: _________ Degree: BSN, MAN f.) PRC NO: 164056 Valid Until: January 25, 2013
b.) PNA NO: 2011-17397 Valid Until: Lifetime Concurred by: ARLENE GALANG-GENEROSA, RN, MAN Signature over printed name of Chief Nurse
Date Signed: ___________ Degree: BSN, MAN c.) PRC NO:152240 Valid Until: October 19, 2014
b.) PNA NO: 18248 Valid Until: Lifetime Approved by: NELIA R. CAPULONG, RN, MAN
Signature over printed name of Dean Date Signed: ____________ Degree: BSN, MAN c.) PRC NO: 0041904
Valid Until: July 31, 2012 b.) PNA NO: 18698 Valid Until: Lifetime c.) ADPCN NO: 0627 Valid Until: December 2010
No. 1. 2. 3. 4. Case No. Diagnosis Name of Mother Age IV. Deliveries Assisted Date of Time of Delivery Delivery Gender of Baby Name of Hospital Type of Delivery Supervised by: Signature of Qualified C.I.
5.
Prepared by: _________________ Signature over printed Name of Student Supervised by: _______________ Signature over printed name of Faculty Date Signed: ____________ Degree: ________________ g.) PRC NO: __________ Valid Until: ________ b.) PNA NO: ___________ Valid Until:_________
Noted by: _____________________ Signature over printed name of Clinical Coordinator Date Signed: __________ Degree:_______________ h.) PRC NO: __________ Valid Until: ________ b.) PNA NO: ___________ Valid Until:_________
Concurred by: _________________________ Signature over printed name of Chief Nurse Date Signed: ___________ Degree:_______________ d.) PRC NO: __________ Valid Until: ____________ b.) PNA NO: ___________ Valid Until: _________
Approved by: Nelia R. Capulong, RN, MAN Signature over printed name of Dean Date Signed: ____________ Degree:________________ d.) PRC NO: ___________ Valid Until: __________ b.) PNA NO: ____________ Valid Until: __________ c.) ADPCN NO:_________ Valid Until: ___________
No. 1. Case No. Date Performed Name of Baby Gender of Baby V. Cord Dressing Name of Mother Age Name of Hospital Supervised by: Signature of Qualified C.I.
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Prepared by: _________________ Signature over printed Name of Student Supervised by: _______________ Signature over printed name of Faculty Date Signed: ____________ Degree: ________________ i.) PRC NO: __________ Valid Until: ________ b.) PNA NO: ___________ Valid Until:_________
Noted by: _____________________ Signature over printed name of Clinical Coordinator Date Signed: __________ Degree:_______________ j.) PRC NO: __________ Valid Until: ________ b.) PNA NO: ___________ Valid Until:_________
Concurred by: _________________________ Signature over printed name of Chief Nurse Date Signed: ___________ Degree:_______________ e.) PRC NO: __________ Valid Until: ____________ b.) PNA NO: ___________ Valid Until: _________
Approved by: Nelia R. Capulong, RN, MAN Signature over printed name of Dean Date Signed: ____________ Degree:________________ e.) PRC NO: ___________ Valid Until: __________ b.) PNA NO: ____________ Valid Until: __________ c.) ADPCN NO:_________ Valid Until: ___________

PRC Form

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OUR LADY OF FATIMA UNIVERSITY #1 Esperanza St.

Hilltop Mansion Heights, Lagro, Quezon City

c.) ADPCN NO: 0627

Valid Until: December 2010

Valid Until: Lifetime

b.) PRC NO: 0041904

Valid Until: July 31, 2012 b.) PNA NO: 18698

Valid Until: Lifetime c.) ADPCN NO: 0627

Valid Until: December 2010

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