CHRIST THE KING COLLEGE

9014 GINGOOG CITY

PHILIPPINES
NURSING PROGRAM
RECORD OF DELIVERY CASES:
[ ] CORD
DRESSING
Name of Patient:
______________________
Case Number:
__________________
Gender of Baby:
______________________
Date/Time of Delivery: __________________
Name of Mother:
______________________
Age:
__________________
Name of Hospital: ______________________________________________________________________________
Diagnosis:
______________________________________________________________________________
__________________________________________________________________________________________________
_
APGAR
Score:
MEDICATION:
Name of Drug
___________________________

Route of
Administration
____________________

___________________________

____________________

___________________________

____________________

___________________________

____________________

ANTHROPOMETRIC MEASUREMENT:
Weight: ______
kg
Height: ______
HC:
______
cm
CC:
______
AC:
______
cm
DR Staff Nurse/Midwife on Duty:
Lic. Number/Expiry Date:
Contact Number:
Name of Student:
Clinical Instructor:
Lic. Number/Expiry Date:
Contact Number:
Delivery RoomNICU
Supervisor:
Lic. Number/Expiry Date:
Contact Number:

cm
cm

Action
________________________________________
_
________________________________________
_
________________________________________
_
________________________________________
_
Vital Signs:
Temp.:
_______
HR:
_______
RR:
_______

C
bpm
cpm

CHRIST THE KING COLLEGE

9014 GINGOOG CITY
PHILIPPINES
NURSING PROGRAM
Record of Delivery Cases:
Name of
Patient:
Age:
Address:

________________________________________

[ ] HANDLE
Case Number: ___________

_______________
Sex:
____________
Civil Status:
____________
__________________________________________________________________________
__
Name of
_______________________________________________________________________
Hospital:
__
Diagnosis:
__________________________________________________________________________
__
__________________________________________________________________________________________
__
OBSTETRICAL HISTORY:
Gravida:
___________
Para: __________
Abortion: _____________
Type of
_________________________________
Gender of
___________
Delivery:
Baby:
Date/Time of Delivery: ____________________
Type of
______________
Episiotomy:
Presentation: ________________________
Position:
___________
Type of Placental Delivery:
______________
Time of Placental
___________
Delivery:
Obstetrician: ______________________________________________
MEDICATION:
Name of Drug
___________________________

Route of Administration
____________________

___________________________

____________________

___________________________

____________________

___________________________

____________________

DR Staff Nurse/Midwife on Duty:

Lic. Number/Expiry Date:
Contact Number:
Name of Student:

Action
_______________________________________
_
_______________________________________
_
_______________________________________
_
_______________________________________
_

Clinical Instructor:
Lic. Number/Expiry Date:
Contact Number:
Delivery RoomNICU
Supervisor:
Lic. Number/Expiry Date:
Contact Number:

CHRIST THE KING COLLEGE

9014 GINGOOG CITY
PHILIPPINES
NURSING PROGRAM
RECORD OF SURGICAL CASES:

[ ] SCRUB [ ] CIRCULATING

Name of Patient: _________________________________________

Case Number: ______________
Age: ___________
Sex: _______________
Civil Status: ________________
Address:
__________________________________________________________________________________________
Name of Hospital:
__________________________________________________________________________________
Pre-operative Diagnosis:
______________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Operation Performed:
________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Post-operative Diagnosis:
_____________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Type of
Anesthesia:
Name of Surgeon:
Name of
Anesthesiologist:
Time of Anesthesia
Began:
Time of Operation
Started:
Date of Operation:
Scrub Nurse:
Lic. Number/Expiry Date:
Contact Number:
Circulating Nurse:
Lic. Number/Expiry Date:
Contact Number:

Time of Anesthesia
Ended:
Time of Operation
Ended:

Name of Student:
Clinical Instructor:
Lic. Number/Expiry Date:
Contact Number:
Operating Room Supervisor:
Lic. Number/Expiry Date:
Contact Number: