ODC Form 1A
Actual Delivery Form
ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728
ACTUAL DELIVERY in_______________________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed name and Signature of Student______________________________________________
Date performed
and
Time Started
Patients INITIAL Only
PROCEDURE
PERFORMED
Case Number
(not applicable for birthing/
D.R Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature not Required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Lying-In Clinics/Homes)
Noted by: ___________________________________
(Print Name and Signature)
Approved by: ____________________________________
Clinical Coordinator, PRC I.D No. _______ Valid Until_______
Date document is signed:________________ Time___________
Please specify Highest Nursing Degree Earned:______________
Dean, PRC I.D No. __________________ Valid Until_____________
Date document is signed:________________ Time________________
Please specify Highest Nursing Degree Earned:___________________
(Print Name and Signature)
(STRICTLY NO DESIGNATES)
ODC Form 1B
Assisted Delivery
Form
ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728
ACTUAL DELIVERY in_______________________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed name and Signature of Student______________________________________________
Date performed
and
Time Started
Patients INITIAL Only
PROCEDURE
PERFORMED
D.R Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature not Required)
Case Number
(not applicable for birthing/
Lying-In Clinics/Homes)
SUPERVISED BY
Clinical Instructor
Name and Signature
ASSISTED DELIVERY
Noted by: ___________________________________
(Print Name and Signature)
Approved by: ____________________________________
Clinical Coordinator, PRC I.D No. _______ Valid Until_______
Date document is signed:________________ Time___________
Please specify Highest Nursing Degree Earned:______________
Dean, PRC I.D No. __________________ Valid Until_____________
Date document is signed:________________ Time________________
Please specify Highest Nursing Degree Earned:___________________
(Print Name and Signature)
(STRICTLY NO DESIGNATES)
ODC Form 1C
Cord Care Form
ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728
IMMEDIATE NEWBORN CORD CARE in OSPITAL NG MAYNILA MEDICAL CENTER, MALATE MANILA
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CELESTINO, KEVIN JAN B.
Date performed
and
Time Started
Patients INITIAL Only
Case Number
(not applicable for birthing/
Immediate Newborn Cord Care
PERFORMED
Nurse On Duty
(Name and Signature)
(If Midwife on Duty,
Signature not Required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Cord Care/Delivery Room
Mariciena Amor C.
Merino R.N.
Rosechelle S.
Elarco R.N. M.A.N.
Cord Care/Delivery Room
Mariciena Amor C.
Merino R.N.
Rosechelle S.
Elarco R.N. M.A.N.
Cord Care/Delivery Room
Mariciena Amor C.
Merino R.N.
Rosechelle S.
Elarco R.N. M.A.N.
(Indicate where performed e.g. DR, Nursery, NICU, or Home)
Lying-In Clinics/Homes)
November 23, 2014
BABY GIRL P.
8:55 pm
690423
November 23, 2014
BABY GIRL A.
9:40 pm
690425
November 24, 2014
BABY GIRL D.
2:58 AM
690427
Noted by: BERNARDITA T. HERNANDEZ R.N. M.A.N. E.d.D.
(Print Name and Signature)
Approved by: ARLENE BLAISE T. CORTEZ R.N. M.A.N. E.d.D.
Level IV Chairman, PRC I.D No.: 0115934Valid Until: August 20, 2015
Date document is signed:________________ Time: ___________
Highest Nursing Degree Earned: B.S.N, M.A.N, E.d.D.
Dean, PRC I.D No.: 0080936 Valid Until: April 6, 2015
Date document is signed:________________ Time: _______________
Highest Nursing Degree Earned:B.S.N, M.A.N, E.d.D.
(Print Name and Signature)
(STRICTLY NO DESIGNATES)
ODC Form 2B
Cord Care Form
ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728
SURGICAL SCRUB in OSPITAL NG MAYNILA MEDICAL CENTER, MALATE MANILA
Hospital Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CELESTINO, KEVIN JAN B.
Date performed
and
Time Started
Patients INITIAL Only
August 12, 2014
B.D.S
2:00 pm
2733039
August 19, 2014
R.A.F.D
3:30 pm
1748990
SURGICAL PROCEDURE
PERFORMED
O.R Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
Hernioplasty, Right
Christian Lloyd M.
Cabusay R.N.
Arleen E. Monterde
R.N., M.A.N.
Low Transverse Ceasarian Section
Christian Lloyd M.
Cabusay R.N.
Arleen E. Monterde
R.N., M.A.N.
Case Number
Noted by: BERNARDITA T. HERNANDEZ R.N. M.A.N. E.d.D.
(Print Name and Signature)
Approved by: ARLENE BLAISE T. CORTEZ R.N. M.A.N. E.d.D.
Level IV Chairman, PRC I.D No.: 0115934Valid Until: August 20, 2015
Date document is signed:________________ Time: ___________
Highest Nursing Degree Earned: B.S.N, M.A.N, E.d.D.
Dean, PRC I.D No.: 0080936 Valid Until: April 6, 2015
Date document is signed:________________ Time: _______________
Highest Nursing Degree Earned:B.S.N, M.A.N, E.d.D.
(Print Name and Signature)
(STRICTLY NO DESIGNATES)
ODC Form 2B
Cord Care Form
ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116
Telefax:833-4728
SURGICAL SCRUB in OSPITAL NG MAYNILA MEDICAL CENTER, MALATE MANILA
Hospital Municipality/City/Province
Prepared by:
Printed name and Signature of Student: CELESTINO, KEVIN JAN B.
Date performed
and
Time Started
Patients INITIAL Only
August 12, 2014
J.H.M.A
6:40pm
2731727
August 19, 2014
C.P.C
2 pm
2733977
SURGICAL PROCEDURE
PERFORMED
O.R Nurse On Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and Signature
Removal of Foreign Body Impaction, Left Ear
Christian Lloyd M.
Cabusay R.N.
Arleen E. Monterde
R.N. M.A.N.
Thoracentesis
Christian Lloyd M.
Cabusay R.N.
Arleen E. Monterde
R.N. M.A.N.
Case Number
Noted by: BERNARDITA T. HERNANDEZ R.N. M.A.N. E.d.D.
(Print Name and Signature)
Approved by: ARLENE BLAISE T. CORTEZ R.N. M.A.N. E.d.D.
Level IV Chairman, PRC I.D No.: 0115934Valid Until: August 20, 2015
Date document is signed:________________ Time: ___________
Highest Nursing Degree Earned: B.S.N, M.A.N, E.d.D.
Dean, PRC I.D No.: 0080936 Valid Until: April 6, 2015
Date document is signed:________________ Time: _______________
Highest Nursing Degree Earned:B.S.N, M.A.N, E.d.D.
(Print Name and Signature)
(STRICTLY NO DESIGNATES)
