D.
R FORM
THE FAMILY CLINIC, INC. - COLLEGES
1452 A. Lacson St. Sta. Cruz, Manila ACTUAL DELIVERY FORM
COLLEGE OF NURSING
ACTUAL DELIVERY in TONDO MEDICAL CENTER - MANILA
Hospital / Home / Lying-in Clinic, Municipality/City/Province
Prepared by: METRA, CATHERINE M.
Patient's INITIAL Only O.R. Nurse On Duty SUPERVISED BY
Date Performed and Time (Not applicable for PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Birthing/Lying-in (If Midwife on Duty, Name and Signature
Started
Clinics/Homes) signature not required)
JANUARY 17, 2020 J.O.C. NORMAL SPONTANEOUS Dra. Kristine Basa Larena V. Hernandez, R.N, M.A.N
6:00 P.M 299098 DELIVERY
JANUARY 16,2020 V.B.G NORMAL SPONTANEOUS Dra. Peraldo Larena V. Hernandez, R.N, M.A.N
6:00 P.M 407666 DELIVERY
JANUARY 16, 2020 L.A.H. NORMAL SPONTANEOUS Dra. Peraldo Larena V. Hernandez, R.N, M.A.N
719621 DELIVERY
Noted by: Concurred by: Approved by:
MA. NENETTE A. GERVACIO R.N, M.A.N. RHODORA D. QUILANTIP R.N., M.A.N ROSEMARIE I. MAGALLANES R.N., M.A.N
(Clinical Coordinator) (Chief Nurse) (Dean)
Date document signed: Date document signed: Date document signed:
Degree: R.N., M.A.N. Degree: R.N., M.A.N. Degree: R.N., M.A.N.
PRC ID No.: 0160789 Valid Until:October 26, 2021 PRC ID No.:0097511 Valid Until: July 8, 2021 PRC ID No.:0150971 Valid Until: January 30, 2022
PNA No.: 000733 Valid Until: December 31, 2022PNA No.:18651 Valid Until: Lifetime Member PNA No.:015012 Valid Until: Lifetime Member
O.R FORM
THE FAMILY CLINIC, INC. - COLLEGES
1452 A. Lacson St. Sta. Cruz, Manila MAJOR SCRUB FORM
COLLEGE OF NURSING
MAJOR OPERATION in TONDO MEDICAL CENTER - MANILA
Hospital / Home / Lying-in Clinic, Municipality/City/Province
Prepared by: METRA, CATHERINE M.
Patient's INITIAL Only O.R. Nurse On Duty SUPERVISED BY
Date Performed and Time (Not applicable for PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Birthing/Lying-in (If Midwife on Duty, Name and Signature
Started
Clinics/Homes) signature not required)
FEBRUARY 17, 2020 B.F. RIGHT HEMICOLECTOMY WITH Sheryl Espiritu R.N. Larena V. Hernandez, R.N, M.A.N
7:00 A.M 743946 END TO END ANASTOMOSIS
FEBRUARY 19,2020 C.N LOW ANTERIOR RESECTION Sheryl Espiritu R.N. Larena V. Hernandez, R.N, M.A.N
7:00 A.M 754392 CHOLECYSTECTOMY
ILEOSTOMY
FEBRUARY 19,2020 S.C.S. MODIFIED RADICAL Sheryl Espiritu R.N. Larena V. Hernandez, R.N, M.A.N
7:00 A.M 764591 MASTECTOMY, RIGHT
Noted by: Concurred by: Approved by:
MA. NENETTE A. GERVACIO R.N, M.A.N. RHODORA D. QUILANTIP R.N., M.A.N ROSEMARIE I. MAGALLANES R.N., M.A.N
(Clinical Coordinator) (Chief Nurse) (Dean)
Date document signed: Date document signed: Date document signed:
Degree: R.N., M.A.N. Degree: R.N., M.A.N. Degree: R.N., M.A.N.
PRC ID No.: 0160789 Valid Until:October 26, 2021 PRC ID No.:0097511 Valid Until: July 8, 2021 PRC ID No.:0150971 Valid Until: January 30, 2022
PNA No.: 000733 Valid Until: December 31, 2022PNA No.:18651 Valid Until: Lifetime Member PNA No.:015012 Valid Until: Lifetime Member
O.R FORM
THE FAMILY CLINIC, INC. - COLLEGES
1452 A. Lacson St. Sta. Cruz, Manila MINOR CASE FORM
COLLEGE OF NURSING
MINOR OPERATION in TONDO MEDICAL CENTER - MANILA
Hospital / Home / Lying-in Clinic, Municipality/City/Province
Prepared by: METRA, CATHERINE M.
Patient's INITIAL Only O.R. Nurse On Duty
Date Performed and Time (Not applicable for PROCEDURE PERFORMED (Name and Signature) SUPERVISED BY
Birthing/Lying-in (If Midwife on Duty, Clinical Instructor
Started
Clinics/Homes) signature not required) Name and Signature
FEBRUARY 24, 2020 P.A.R. EXCISION LYMPHOMA Adrian L. Llarenas Orlando V. Santos, R.N, M.A.N
7:00 A.M 743946
FEBRUARY 19, 2020 I.G. INCISION AND DRAINAGE Adrian L. Llarenas. Orlando V. Santos, R.N, M.A.N
743934 ABCESS LEFT THUMB
FEBRUARY 17, 2020 A.R. EXCISION OF SEBACEOUS CYST Adrian L. Llarenas
743925 LEFT FOREARM Orlando V. Santos, R.N, M.A.N
Noted by: Concurred by: Approved by:
MA. NENETTE A. GERVACIO R.N, M.A.N. RHODORA D. QUILANTIP R.N., M.A.N ROSEMARIE I. MAGALLANES R.N., M.A.N
(Clinical Coordinator) (Chief Nurse) (Dean)
Date document signed: Date document signed: Date document signed:
Degree: R.N., M.A.N. Degree: R.N., M.A.N. Degree: R.N., M.A.N.
PRC ID No.: 0160789 Valid Until:October 26, 2021 PRC ID No.:0097511 Valid Until: July 8, 2021 PRC ID No.:0150971 Valid Until: January 30, 2022
PNA No.: 000733 Valid Until: December 31, 2022PNA No.:18651 Valid Until: Lifetime Member PNA No.:015012 Valid Until: Lifetime Member
D. R. FORM
THE FAMILY CLINIC, INC. - COLLEGES
1452 A. Lacson St. Sta. Cruz, Manila DELIVERY ASSIST FORM
COLLEGE OF NURSING
IMMEDIATE CARE OF THE NEWBORN FORM in TONDO MEDICAL CENTER - MANILA
Hospital / Home / Lying-in Clinic, Municipality/City/Province
Prepared by: METRA, CATHERINE M.
Patient's INITIAL Only O.R. Nurse On Duty SUPERVISED BY
Date Performed and Time (Not applicable for PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Birthing/Lying-in (If Midwife on Duty, Name and Signature
Started
Clinics/Homes) signature not required)
JANUARY 17, 2020 E.M.B NORMAL SPONTANEOUS Dra. Kristine Basa Larena V. Hernandez, R.N, M.A.N
6:00 P.M 297457 DELIVERY
JANUARY 16,2020 B.G.M. NORMAL SPONTANEOUS Larena V. Hernandez, R.N, M.A.N
6:00 P.M 407686 DELIVERY Dra. Peraldo
JANUARY 15, 2020 M.U.D. NORMAL SPONTANEOUS Dra. Kristine Basa Larena V. Hernandez, R.N, M.A.N
6:00 P.M 407888 DELIVERY
Noted by: Concurred by: Approved by:
MA. NENETTE A. GERVACIO R.N, M.A.N. RHODORA D. QUILANTIP R.N., M.A.N ROSEMARIE I. MAGALLANES R.N., M.A.N
(Clinical Coordinator) (Chief Nurse) (Dean)
Date document signed: Date document signed: Date document signed:
Degree: R.N., M.A.N. Degree: R.N., M.A.N. Degree: R.N., M.A.N.
PRC ID No.: 0160789 Valid Until:October 26, 2021 PRC ID No.:0097511 Valid Until: July 8, 2021 PRC ID No.:0150971 Valid Until: January 30, 2022
PNA No.: 000733 Valid Until: December 31, 2022PNA No.:18651 Valid Until: Lifetime Member PNA No.:015012 Valid Until: Lifetime Member
O.R FORM
THE FAMILY CLINIC, INC. - COLLEGES
1452 A. Lacson St. Sta. Cruz, Manila MAJOR CIRCULATING
COLLEGE OF NURSING FORM
MAJOR OPERATION in TONDO MEDICAL CENTER - MANILA
Hospital / Home / Lying-in Clinic, Municipality/City/Province
Prepared by: METRA, CATHERINE M.
Patient's INITIAL Only O.R. Nurse On Duty SUPERVISED BY
Date Performed and Time (Not applicable for PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Birthing/Lying-in (If Midwife on Duty, Name and Signature
Started
Clinics/Homes) signature not required)
FEBRUARY 10, 2020 B.M. OPEN CHOLECYSTECTOMY CARMEN S. YABUT R.N. Larena V. Hernandez, R.N, M.A.N
7:00 A.M 556992 MAN.
FEBRUARY 17,2020 B.C.O. MODIFIED RADICAL E-JAY C. MORALES R.N. Larena V. Hernandez, R.N, M.A.N
7:00 A.M 706058 MASTECTOMY, LEFT
FEBRUARY 19,2020 J.R. CECECTOMY DOUBLE BARREL LUZVIMINDA S. BALETA Larena V. Hernandez, R.N, M.A.N
7:00 A.M 754410 CLEOSTOMY COLOSTOMY R.N.
Noted by: Concurred by: Approved by:
MA. NENETTE A. GERVACIO R.N, M.A.N. RHODORA D. QUILANTIP R.N., M.A.N ROSEMARIE I. MAGALLANES R.N., M.A.N
(Clinical Coordinator) (Chief Nurse) (Dean)
Date document signed: Date document signed: Date document signed:
Degree: R.N., M.A.N. Degree: R.N., M.A.N. Degree: R.N., M.A.N.
PRC ID No.: 0160789 Valid Until:October 26, 2021 PRC ID No.:0097511 Valid Until: July 8, 2021 PRC ID No.:0150971 Valid Until: January 30, 2022
PNA No.: 000733 Valid Until: December 31, 2022PNA No.:18651 Valid Until: Lifetime Member PNA No.:015012 Valid Until: Lifetime Member
O.R FORM
THE FAMILY CLINIC, INC. - COLLEGES
1452 A. Lacson St. Sta. Cruz, Manila IMMEDIATE CARE OF THE
COLLEGE OF NURSING NEWBORN FORM
IMMEDIATE CARE OF THE NEWBORN in TONDO MEDICAL CENTER - MANILA
Hospital / Home / Lying-in Clinic, Municipality/City/Province
Prepared by: METRA, CATHERINE M.
Patient's INITIAL Only O.R. Nurse On Duty SUPERVISED BY
Date Performed and Time (Not applicable for PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Birthing/Lying-in (If Midwife on Duty, Name and Signature
Started
Clinics/Homes) signature not required)
JANUARY 15, 2020 S.Q.C NORMAL SPONTANEOUS Rosalinda C.Sagario, R.N. Larena V. Hernandez, R.N, M.A.N
6:00 P.M 644592 DELIVERY
JANUARY 15, 2020 J.A. NORMAL SPONTANEOUS Annalia Pelagio R.N. Larena V. Hernandez, R.N, M.A.N
6:00 P.M 617461 DELIVERY .
JANUARY 15, 2020 M.J.B. NORMAL SPONTANEOUS Teresita Pagwagan R.N. Larena V. Hernandez, R.N, M.A.N
6:00 P.M 645887 DELIVERY
Noted by: Concurred by: Approved by:
MA. NENETTE A. GERVACIO R.N, M.A.N. RHODORA D. QUILANTIP R.N., M.A.N ROSEMARIE I. MAGALLANES R.N., M.A.N
(Clinical Coordinator) (Chief Nurse) (Dean)
Date document signed: Date document signed: Date document signed:
Degree: R.N., M.A.N. Degree: R.N., M.A.N. Degree: R.N., M.A.N.
PRC ID No.: 0160789 Valid Until:October 26, 2021 PRC ID No.:0097511 Valid Until: July 8, 2021 PRC ID No.:0150971 Valid Until: January 30, 2022
PNA No.: 000733 Valid Until: December 31, 2022PNA No.:18651 Valid Until: Lifetime Member PNA No.:015012 Valid Until: Lifetime Member
