Republic of the Philippines
OR Form
Biliran Province State University Scrub Nurse
(formerly NAVAL STATE UNIVERSITY)
ISO 9001:2015 CERTIFIED
SCHOOL OF NURSING AND HEALTH SCIENCES
SCRUB NURSE in BILIRAN PROVINCIAL HOSPITAL, NAVAL, BILIRAN
Prepared by: NGOHO, JINKY MIE MANAHON
Patient’s INITIALS (only)
Date Performed SUPERVISED BY
OR Nurse On Duty
and PROCEDURE PERFORMED Clinical Instructor
(Name and Signature)
Time Started (Name and Signature)
Case Number
SILLMARK T. BACASON, PhD, RN
PRC No: 0381173
11-16-2022 A. L. L.
Hernioplasty Right, Herniorrhaphy Right Valid Until: 01-17-2027
@4:28 PM Case No: 25-00-29
PNA No: ___________
HERBIE M. DELDA, RN Valid Until: __________
Noted by: Approved by:
BABY DANICA B. NUÑEZ, MAN, RN JOVY DIA R. SANIEL, Ph.D.N.Sc.
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: ________________ Date Signed: ________________
Degree: Master of Arts in Nursing Degree: Doctor of Philosophy in Nursing Science
a.) PRC No : 0892817 a.) PRC No: 0348573
Valid Until : 11-10-2026 Valid Until: 08-14-2026
b.) PNA No : b.) PNA No: Lifetime No. 17095
Valid Until : Valid Until: Lifetime
c.) ADPCN No.: 16668
Valid Until: 06-2025
Ground Floor Administration Building, Main Campus, P. Inocentes St., P.I. Garcia, Naval, Biliran Province, Philippines 6560 SNHS – PRCSNF
Tel. (053) 507-9023 ןTelefax. (053) 507-9023 Page 1 of 1
07/31/2023
SUC Level III-A (Per DBM-CHED Joint Circular #B dated June 21, 2007 Rev. 01
Website: www.bipsu.edu.ph ןEmail: [email protected] ןFacebook: www.facebook.com/Bipsuschoolofnursingandhealthsciences
#WoWBiPSU!
Republic of the Philippines
OR Form
Biliran Province State University Scrub Nurse
(formerly NAVAL STATE UNIVERSITY)
ISO 9001:2015 CERTIFIED
SCHOOL OF NURSING AND HEALTH SCIENCES
SCRUB NURSE in EASTERN VISAYAS REGIONAL MEDICAL CENTER, TACLOBAN CITY
Prepared by: NGOHO, JINKY MIE MANAHON
Date Performed Patient’s INITIALS (only) SUPERVISED BY
OR Nurse On Duty
and PROCEDURE PERFORMED Clinical Instructor
(Name and Signature)
Time Started Case Number (Name and Signature)
SILLMARK T. BACASON, PhD, RN
PRC No: 0381173
11-23-2022 J. O
Emergency Mesh Hernioplasty, Left Valid Until: 01-17-2027
@12:43 AM Case No: 35-06-43
PNA No: ___________
DIANE A. ESTANISLAO, RN Valid Until: __________
BERNA B. SALLAVE, MAN, RN
05-29-2022 A. R. Q PRC No: 0832016
Emergency Appendectomy
@9:04PM Case No: 37-10-93 Valid Until: 12-08-2027
PNA No: ___________
ENRICO O. CLAROS, RN Valid Until: __________
BERNA B. SALLAVE, MAN, RN
05-30-2023 PRC No: 0832016
A. C. M. Open Reduction Intramedullary Nailing, Right Tibia,
@5:55 PM Valid Until: 12-08-2027
Case No: 36-72-65 Iliac Bone Grafting
PNA No: ___________
JASON B. SONGALIA, RN Valid Until: __________
Noted by: Approved by:
BABY DANICA B. NUÑEZ, MAN, RN JOVY DIA R. SANIEL, Ph.D.N.Sc.
Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: ________________ Date Signed: ________________
Degree: Master of Arts in Nursing Degree: Doctor of Philosophy in Nursing Science
a.) PRC No : 0892817 a.) PRC No: 0348573
Valid Until : 11-10-2026 Valid Until: 08-14-2026
b.) PNA No : b.) PNA No: Lifetime No. 17095
Valid Until : Valid Until: Lifetime
c.) ADPCN No.: 16668
Valid Until: 06-2025
Ground Floor Administration Building, Main Campus, P. Inocentes St., P.I. Garcia, Naval, Biliran Province, Philippines 6560 SNHS – PRCSNF
Tel. (053) 507-9023 ןTelefax. (053) 507-9023 Page 1 of 1
SUC Level III-A (Per DBM-CHED Joint Circular #B dated June 21, 2007 07/31/2023
Rev. 01
Website: www.bipsu.edu.ph ןEmail: [email protected] ןFacebook: www.facebook.com/Bipsuschoolofnursingandhealthsciences
#WoWBiPSU!
