UNIVERSITY OF PANGASINAN ODC Form 2A

Phinma Education Network O.R. SCRUB FORM

MAJOR
Arellano St., Dagupan City
Phone No.: (075)522-5635 to 37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level 1 PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB in: Hospital, Municipality/City, Province

Prepared by:
Printed Name with Signature of Student: SANTOS, Paul Christian Padama

Date Performed Patient’s initials SURGICAL PROCEDURE O. R. Nurse on Duty SUPERVISED BY

AND PERFORMED
Case Number
Time Started
December 01, 2009 A.B.C. Appendectomy Ms. I-Am D. Ci, RN Ms. Ci Din N. Ako, RN
7:45 AM 123456

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No.: 0133422 Valid Until: July 27, 2011 Dean, PRC No.: 0100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PhD
 UNIVERSITY OF PANGASINAN ODC Form 2B
Phinma Education Network O.R. SCRUB FORM
MINOR
Arellano St., Dagupan City
Phone No.: (075)522-5635 to 37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level 1 PACUCOA; Year Granted: March 05, 2007)

SURGICAL SCRUB in: Hospital, Municipality/City, Province

Prepared by:
Printed Name with Signature of Student: SANTOS, Paul Christian Padama

Date Performed Patient’s initials SURGICAL PROCEDURE O. R. Nurse on Duty SUPERVISED BY

AND PERFORMED
Case Number
Time Started
December 01, 2009 A.B.C. Circumcision Ms. I-Am D. Ci, RN Ms. Ci Din N. Ako, RN
7:45 AM 78910

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No.: 0133422 Valid Until: July 27, 2011 Dean, PRC No.: 0100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PhD
 UNIVERSITY OF PANGASINAN ODC Form 1A
Phinma Education Network ACTUAL DELIVERY
FORM
Arellano St., Dagupan City
Phone No.: (075)522-5635 to 37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level 1 PACUCOA; Year Granted: March 05, 2007)

ACTUAL DELIVERY(IES) in: Hospital, Municipality/City, Province

DELIVERY= 1 case only
DELIVERIES=2 cases above
Prepared by:
Printed Name with Signature of Student: SANTOS, Paul Christian Padama

Date Performed Patient’s initials PROCEDURE D. R. Nurse on Duty SUPERVISED BY

AND PERFORMED Replace “D. R. Nurse” with
Case Number
Time Started Midwife if in DLMLC
Alaminos
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No.: 0133422 Valid Until: July 27, 2011 Dean, PRC No.: 0100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PhD
 UNIVERSITY OF PANGASINAN ODC Form 1C
Phinma Education Network ASSISTED
DELIVERY FORM
Arellano St., Dagupan City
Phone No.: (075)522-5635 to 37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level 1 PACUCOA; Year Granted: March 05, 2007)

ACTUAL DELIVERY(IES) in: Hospital, Municipality/City, Province

DELIVERY= 1 case only
DELIVERIES=2 cases above
Prepared by:
Printed Name with Signature of Student: SANTOS, Paul Christian Padama

Date Performed Patient’s initials PROCEDURE D. R. Nurse on Duty SUPERVISED BY

AND PERFORMED Replace “D. R. Nurse” with
Case Number
Time Started Midwife if in DLMLC
Alaminos
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery
Normal Spontaneous
Delivery

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No.: 0133422 Valid Until: July 27, 2011 Dean, PRC No.: 0100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PhD
 UNIVERSITY OF PANGASINAN ODC Form 1C
Phinma Education Network CORD CARE FORM
Arellano St., Dagupan City
Phone No.: (075)522-5635 to 37; Fax No.: (075)522-2496; Email: registrar@upang.edu.ph; Website: http://www.upang.edu.ph
(Level 1 PACUCOA; Year Granted: March 05, 2007)

IMMEDIATE NEWBORN CORD CARE in: Hospital, Municipality/City, Province

Prepared by:
Printed Name with Signature of Student: SANTOS, Paul Christian Padama

Date Performed Patient’s initials Immediate Newborn Cord Nurse on Duty SUPERVISED BY
AND Care PERFORMED Replace “Nurse” with
Case Number
Time Started (Please indicate where the Midwife if in DLMLC
procedure was performed) Alaminos
Normal Spontaneous Delivery,
Delivery Room
Normal Spontaneous Delivery,
Nursery

Noted by: ZENAIDA M. BAUTISTA Approved by: MELANIA C. CENON

Clinical Coordinator, PRC No.: 0133422 Valid Until: July 27, 2011 Dean, PRC No.: 0100236 Valid Until: January 06, 2012
Date document is signed: Time: Date document is signed: Time:
Degree Earned: BSN-RN, MAN Degree Earned: BSN-RN, MAN, MAEd, PhD