Doa Remedios Trinidad Romualdez Medical Foundation

Calanipawan Road, Calanipawan, Tacloban City 6500 Philippines

Tel. Nos.(053) 321-2345/ 321-4150/ 325-8353/ 327-5634/ 327-1776, Telefax Nos. (053) 327-5506/ 327-5004, E-mail
address: rtr1980@yahoo.com
MAJOR CIRCULATING in EASTERN VISAYAS REGIONAL MEDICAL CENTER, Tacloban City, Leyte

Prepared by: JABEZ HERALD B. TY

DATE PERFORMED AND
TIME STARTED

PATIENTS INITIALS
(ONLY)
CASE NUMBER

SURGICAL PROCEDURE

O.R. NURSE ON DUTY

(NAME AND SIGNATURE)

SUPERVISED BY CLINICAL
INSTRUCTOR
(NAME AND SIGNATURE)

July 3, 2013
Time started: 09: 35 AM

T.D.
61-88-05

Elective Modified Radical

Mastectomy Right

RICHARD NORIEL D.
TOMAUB, R.N.

LOURADEL M. ULBATA, M.A.N.,

R.N.

Noted by: MRS. JESUSA M. MAGNO, M.A.N., R.N.

GASCO, D.M., HRM, M.N., R.N.
Clinical Coordinator
PRC I.D No.0136071 Valid Until: December 2017
PNA No.14275
Valid Until: Life member
Date document is signed: ___________Time___________
Highest Nursing Degree Earned: Master of Arts in Nursing
___________Time___________

Approved by:

DR. SOCORRO SALVACION

Dean, College of Nursing

PRC I.D No. 0063136 Valid Until: June 2016
PNA No. 01219 Valid Until: Life member
ADPCN No. 11-192 Valid Until: June 2015
Date document is signed:
Highest Nursing Degree Earned:

Doctor of Management

SUBSCRIBED AND SWORN to before me this ________________________ at Tacloban City by the above parties who presented their
competence evidence of identities.