COLLEGE OF THE HOLY SPIRIT MANILA

163 E. Mendiola St., P.O. Box 1817

Manila, 1005 Philippines
Tel No.(632) 735-6021 Loc 401Fax No. (632) 735-5989

www.holyspirit.edu.ph

O.R. FORM 1A
O.R. SCRUB FORM
MAJOR

SURGICAL SCRUB in OUR LADY OF LOURDES HOSPITAL MANILA

Hospital
Prepared By:
Printed Name and Signature VICKY GORME QUILLOPE
Date Performed
and
Time Started

Patients INITIAL Only

SURGICAL PROCEDURE

O.R. Nurses on Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Case Number

PERFORMED

December 7, 2011
8:35AM

J.J.R.R.
181142

Right Salphingooopherectomy
Adhesiolysis

Gabriel Bacasmas, RN

Sr. Anna Virginia Magpily

SSpS, RN, MAN

December 13, 2011

8:58AM

A.C.C.
181211

Exploratory Laparotomy Biliary

Surgery Possible Whipple
Procedure

Rogenard Gerard
Pangan, RN

Sr. Anna Virginia Magpily

SSpS, RN, MAN

January 11, 2012

8:02AM

L.A.G
181405

Phacoemulsification with
Posterior Cataract Intraoccular
Lense pseudophokia OD

Gabriel Bacasmas, RN

Sr. Anna Virginia Magpily

SSpS, RN, MAN

Noted By: _____________________________

(Printed Name and Signature)

Approved By: ___________________________________

(Printed Name and Signature)

Clinical Coordinator, PRC I.D _________ Valid until _________

Date documented is signed: _________ Time _________
Please specify Highest Nursing Degree Earned __________

Dean, PRC I.D No. __________Valid until ____________

Date documented is signed: _________ Time _________
Please specify Highest Nursing Degree Earned ________

COLLEGE
OF NO
THE
HOLY SPIRIT MANILA
(STRICTLY
DESIGNATES)
163 E. Mendiola St., P.O. Box 1817
Manila, 1005 Philippines
Tel No.(632) 735-6021 Loc 401Fax No. (632) 735-5989

www.holyspirit.edu.ph

O.R. FORM 1B
O.R. CIRCULATING
FORM

CIRCULATING in OUR LADY OF LOURDES HOSPITAL MANILA

Hospital
Prepared By:
Printed Name and Signature VICKY GORME QUILLOPE
Date Performed
and
Time Started

Patients INITIAL Only

SURGICAL PROCEDURE

Case Number

PERFORMED

December 6, 2011
11:40AM

F.A.P
181135

December 12, 2011

7:55AM

N.V.B
181194

December 12, 2011

12:05PM

C.S.B
181199

Exploratory Laparotomy
Subtotal Abdominal
Hysterectomy bilateral
Salphyngooophorectomy
Adhesiolysis
Total Thyroidectomy Central
Nodule Dissection with =
without (Hashimotos Thyroiditis
with central nodule hyperplastic
Reaction)
Excision biopsy right with
Frozen Section (+) Modified
Radical Mastectomy, Right

O.R. Nurses on Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Kristine Rose
Bermundo, RN

Sr. Anna Virginia Magpily

SSpS, RN, MAN

Joyce Abegail Arcos,

RN

Sr. Anna Virginia Magpily

SSpS, RN, MAN

Kristine Rose
Bermundo, RN

Sr. Anna Virginia Magpily

SSpS, RN, MAN

Noted By: _____________________________

(Printed Name and Signature)

Approved By: ___________________________________

(Printed Name and Signature)

Clinical Coordinator, PRC I.D _________ Valid until _________

Date documented is signed: _________ Time _________
Please specify Highest Nursing Degree Earned __________

Dean, PRC I.D No. __________Valid until ____________

Date documented is signed: _________ Time _________
Please specify Highest Nursing Degree Earned ________

(STRICTLY NO DESIGNATES)
COLLEGE OF THE HOLY SPIRIT MANILA
163 E. Mendiola St., P.O. Box 1817
Manila, 1005 Philippines
Tel No.(632) 735-6021 Loc 401Fax No. (632) 735-5989

www.holyspirit.edu.ph

ICNB Form
IMMEDIATE CARE OF
THE
NEWBORN FORM

IMMEDIATE CARE OF THE NEWBORN CORD CARE in OUR LADY OF LOURDES HOSPITAL MANILA
Hospital
Prepared By:
Printed Name and Signature VICKY GORME QUILLOPE
Date Performed
and
Time Started

Patients INITIAL Only

Immediate Newborn
Cord care

Nursery Nurses on Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

January 19, 2011

8:43AM

Baby Girl of K.C

360180

Anthropometrics Nursery
Cord care

Sheryl Ann Pineda, RN

Sr. Anna Virginia Magpily

SSps, RN

January 25, 2011

9:08AM

Baby Girl of A.D

360285

Anthropometrics Nursery
Cord care

Sheryl Ann Pineda, RN

Sr. Anna Virginia Magpily

SSps, RN

November 23, 2010

6:49AM

Baby Boy of F.A

35911

Anthropometrics Nursery
Cord care

Sheryl Ann Pineda, RN

Sr. Anna Virginia Magpily

SSps, RN

Case Number

Noted By: _____________________________

(Printed Name and Signature)

Approved By: ___________________________________

(Printed Name and Signature)

Clinical Coordinator, PRC I.D _________ Valid until _________

Date documented is signed: _________ Time _________

Dean, PRC I.D No. __________Valid until ____________

Date documented is signed: _________ Time _________

Please specify Highest Nursing Degree Earned __________

Please specify Highest Nursing Degree Earned ________

COLLEGE
OF THE
SPIRIT MANILA
(STRICTLY
NOHOLY
DESIGNATES)
163 E. Mendiola St., P.O. Box 1817
Manila, 1005 Philippines
Tel No.(632) 735-6021 Loc 401Fax No. (632) 735-5989

D.R. FORM
ACTUAL DELIVERY
FORM

www.holyspirit.edu.ph

ACTUAL DELIVERY in OUR LADY OF LOURDES HOSPITAL MANILA

Hospital
Prepared By:
Printed Name and Signature VICKY GORME QUILLOPE
Date Performed
and
Time Started

Patients INITIAL Only

ACTUAL DELIVERY

DR Nurses on Duty
(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Case Number

PERFORMED

September 17, 2012

2:22PM

M.P.G
18593

Normal Spontaneous Delivery

Maria Kristine Villaraza,

RN

Sr. Anna Virginia

Magpily SSps, RN

September 19, 2012

6:47AM

S.A.P
18598

Normal Spontaneous Delivery

Maria Kristine Villaraza,

RN

Sr. Anna Virginia

Magpily SSps, RN

January 21, 2013

7:19AM

E.P.N
18878

Normal Spontaneous Delivery

Ruth Camero, RN

Sr. Anna Virginia

Magpily SSps, RN

Noted By: _____________________________

(Printed Name and Signature)

Approved By: ___________________________________

(Printed Name and Signature)

Clinical Coordinator, PRC I.D _________ Valid until _________

Dean, PRC I.D No. __________Valid until ____________

Date documented is signed: _________ Time _________

Please specify Highest Nursing Degree Earned __________

Date documented is signed: _________ Time _________

Please specify Highest Nursing Degree Earned ________

(STRICTLY NO DESIGNATES)