COLLEGE OF OUR LADY OF MT.

CARMEL
Km. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing

Name of Student: ____________________

Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____
Accreditation Level (if any): N/A Year Granted: N/A ____
Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____
First Course (if any) : ____School Graduated From: Year: ____________________
Year of Admission in the Bachelor of Science in Nursing Program: ____
Year Graduated (BSN Program): ____________

I. MAJOR OPERATIONS
Signature of
Date of Case Type of
No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital Name of OR Scrub Nurse OR Scrub
Operation No. Anesthesia
Nurse

Concurred by: Concurred by: Approved by:

__________________________________________________

Chief Nurse, Our Lady of Mt. Carmel Medical Center Chief Nurse, Romana Pangan District Hospital Dean, College of Nursing
Date Signed: _____________________________ Date Signed: ________________________________ College of Our Lady of Mt. Carmel (Pampanga)
Degree: ____________________ _____________ Degree: ____ __________________ Date Signed: __________________________________
Degree: __________________________________
a. PRC No.: _______________________ a. PRC No.: _____ __________ a. PRC No.: ______________________________
Valid Until: _____ ________________ Valid Until: _____ __________ Valid Until: _____________________________
b. PNA No.: _____ __________ b. PNA No.: _____ _________________
b. PNA No.: ______________________________
Valid Until: ______________________________
Valid Until: _____ ___________ Valid Until: _______________ _________ c. ANSAP No.: ___________________________
c. ANSAP No.: _____________________ c. ANSAP No.: ________________________ Valid Until: _____ _____________________
Valid Until: _____ ___________ Valid Until: _____ ______________

Noted by:

_____________________________________________

Clinical Coordinator
Date Signed: __________________________________
Degree: ____________________________________ Prepared by:
a. PRC No.: _____________________________ ____________________________________
Valid Until: ____________________________
b. PNA No.: ____________________________ Student Nurse
Valid Until: ____________________________
c. ANSAP No.: _______________________
 COLLEGE OF OUR LADY OF MT. CARMEL
Km. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing

Name of Student: ____________________

Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____
Accreditation Level (if any): N/A Year Granted: N/A ____
Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____
First Course (if any) : ____School Graduated From: Year: ____________________
Year of Admission in the Bachelor of Science in Nursing Program: ____
Year Graduated (BSN Program): ____________

II. MINOR OPERATIONS

Signature of
Date of Type of
No. Case No. Name of Patient Diagnosis Operation Performed Name of Surgeon Name of Hospital Name of OR Scrub Nurse OR Scrub
Operation Anesthesia
Nurse

Concurred by Concurred by: Concurred by: Approved by:

_________________________________________
_________________________________________ _______________________________________________ _____________________________________
Chief Nurse,
Chief Nurse, Our Lady of Mt. Carmel Medical Center Chief Nurse, Porac District Hospital Date Signed: _____________________________ Dean, College of Nursing
Date Signed: _____________________________ Date Signed: ____________________________________ Degree: ____________________ _____________ College of Our Lady of Mt. Carmel (Pampanga)
Degree: ____________________ _____________ Degree: _____ __________________________ Date Signed: __________________________________
a. PRC No.: _____ ______________________ a. PRC No.: _______________________ Degree: __________________________________
a. PRC No.: _______________________ Valid Until: _______________________________ Valid Until: _____ ________________ a. PRC No.: _____________________________
Valid Until: _____ ________________ b. PNA No.: _____ _____________________
b. PNA No.: _____ __________
Valid Until: ____________________________
b. PNA No.: _____ __________
c.
Valid Until: _____ _____________________ _
ANSAP No.: _____________________________ Valid Until: _____ ___________
b. PNA No.: ______________________________
Valid Until: _____________________________
Valid Until: _____ ___________ c. ANSAP No.: ____________________
Valid Until: _____ __________________ c. ANSAP No.: ____________________________
c. ANSAP No.: ____________________ Valid Until: _____ __________
Valid Until: _____ __________ Valid Until: _____ _________________

Noted by:
______________________________________________

Clinical Coordinator Prepared by:

Date Signed: __________________________________ ____________________________________
Degree: ____________________________________ Student Nurse
a. PRC No.: _____________________________
Valid Until: ____________________________
b. PNA No.: _____________________________
Valid Until: ____________________________
c. ANSAP No.: __________________________
Valid Until: _____ _________________
 COLLEGE OF OUR LADY OF MT. CARMEL
Km. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing

Name of Student: ____________________

Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____
Accreditation Level (if any): N/A Year Granted: N/A ____
Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____
First Course (if any) : ____School Graduated From: Year: ____________________
Year of Admission in the Bachelor of Science in Nursing Program: ____
Year Graduated (BSN Program): ____________
III. ACTUAL DELIVERIES

Case Date of Time of Gender Supervised by: Name and

No. Diagnosis Name of Mother Age Name of Hospital Type of Delivery
No. Delivery Delivery of Baby Signature of Qualified
Clinical Instructor

Concurred by: Concurred by: Concurred by: Approved by:

_________________________________________ _________________________________________ _______________________________________________ __________________________________________________
Trinidad Yambing Chief Nurse,
Chief Nurse, Date Signed: _____________________________ Chief Nurse, Dean, College of Nursing
Date Signed: _____________________________ Degree: ____________________ _____________ Date Signed: ____________________________________ College of Our Lady of Mt. Carmel (Pampanga)
Degree: ____________________ _____________ Degree: _____ __________________________ Date Signed: __________________________________
c. PRC No.: _______________________ a. PRC No.: _____ ______________________ Degree: __________________________________
a. PRC No.: _______________________ Valid Until: _____ ________________ Valid Until: _______________________________ a. PRC No.: _____________________________
Valid Until: _____ ________________
d. PNA No.: _____ __________ b. PNA No.: _____ _____________________ Valid Until: ____________________________
b. PNA No.: _____ __________ Valid Until: _____ ___________
c.
Valid Until: _____ _____________________ _
ANSAP No.: ____________________ _________
b. PNA No.: _____________________________
Valid Until: _____________________________
Valid Until: _____ ___________ c. ANSAP No.: ____________________
c. ANSAP No.: ____________________ Valid Until: _____ __________ Valid Until: _____ __________________ c. ANSAP No.: ___________________________
Valid Until: _____ __________________
Valid Until: _____ __________
____________________________

Noted by:

______________________________________________

Clinical Coordinator
Date Signed: __________________________________ Prepared by:
Degree: ____________________________________ ____________________________________
a. PRC No.: _____________________________
Valid Until: ____________________________
b. PNA No.: _____________________________ Student Nurse
Valid Until: ____________________________
c. ANSAP No.: ___________________________
Valid Until: _____ _________________
 COLLEGE OF OUR LADY OF MT. CARMEL
Km. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing

Name of Student: ________________

Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _
Accreditation Level (if any): N/A Year Granted: N/A
Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008
First Course (if any) : ____School Graduated From: Year: ________________
Year of Admission in the Bachelor of Science in Nursing Program:
Year Graduated (BSN Program):
IV. DELIVERIES ASSISTED
Case Date of Time of Gender Type of Supervised by:
No. Diagnosis Name of Mother Age Name of Hospital
No. Delivery Delivery of Baby Delivery Name & Signiture of C.I.

Concurred by: Concurred by: Approved by:

___________________________________________ _______________________________________________ ________________________________________

Chief Nurse, Our Lady of Mt. Carmel Medical Center Chief Nurse, Romana Pangan District Hospital Dean, College of Nursing
Date Signed: ________________________________ Date Signed: ____________________________________ College of Our Lady of Mt. Carmel (Pampanga)
Degree: ____ __________________ Degree: _____ __________________________ Date Signed: __________________________________
a. PRC No.: _____ ______________________ Degree: __________________________________
a. PRC No.: _____ __________ Valid Until: _______________________________ a. PRC No.: _____________________________
Valid Until: _____ __________ b. PNA No.: _____ _____________________ Valid Until: ____________________________
b. PNA No.: _____ _________________
c.
Valid Until: _____ _____________________ _
ANSAP No.: ____________________
b. PNA No.: ______________________________
Valid Until: ____________________________
Valid Until: _______________ _________
c. ANSAP No.: _______________________ Valid Until: _____ __________ c. ANSAP No.: ___________________________
Valid Until: _____ __________________
Valid Until: _____ ______________

Noted by:

______________________________________________

Clinical Coordinator
Date Signed: __________________________________
Degree: ____________________________________
a. PRC No.: _____________________________ Prepared by:
Valid Until: ____________________________ ____________________________________
b. PNA No.: _____________________________
Valid Until: ____________________________
c. ANSAP No.: ___________________________ Student Nurse
Valid Until: _____ _________________
 COLLEGE OF OUR LADY OF MT. CARMEL
Km. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing

Name of Student: ____________________

Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____
Accreditation Level (if any): N/A Year Granted: N/A ____
Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____
First Course (if any) : ____School Graduated From: Year: ____________________
Year of Admission in the Bachelor of Science in Nursing Program: ____
Year Graduated (BSN Program): ____________

V. CORD DRESSING

Date Gender of
No. Case No. Name of Baby Name of Mother Age Name of Hospital Supervised by: Name and Signature of Qualified C.I.
Performed Baby

Concurred by: Concurred by: Approved by:

_________________________________________ ___________________________________________ __________________________________________________

Chief Nurse, Romana Pangan District Hospital Chief Nurse, Dean, College of Nursing
Date Signed: _____________________________ Date Signed: ________________________________ College of Our Lady of Mt. Carmel (Pampanga)
Degree: ____________________ _____________ Degree: ____ __________________ Date Signed: __________________________________
Degree: ________________________________
a. PRC No.: _______________________ a. PRC No.: _____ __________ a. PRC No.: _____________________________
Valid Until: _____ ________________ Valid Until: _____ __________ Valid Until: ____________________________
b. PNA No.: _____ __________ b. PNA No.: _____ _________________ b. PNA No.: _____________________________
Valid Until: _____ _________________
Valid Until: _____ ___________ Valid Until: _______________ _________
c. ANSAP No.: ________________________ c. ANSAP No.: ___________________________
Valid Until: _____ ________________
Valid Until: _____ _________________

Noted by:

______________________________________________

Clinical Coordinator
Date Signed: __________________________________
Degree: ____________________________________
a. PRC No.: _____________________________
Valid Until: ____________________________ Prepared by:
b. PNA No.: _____________________________ ____________________________________
Valid Until: ____________________________
c. ANSAP No.: ________________________ Student Nurse
Valid Until: _____ _________________