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    This document is a surgical scrub form from the University of Perpetual Help System - GMA Campus. It contains fields for the student's name and signature, date and time of the procedure, patient information, procedure performed, supervising nurse and clinical instructor signatures. The form also documents approvals from the chief nurse, clinical coordinator and dean of the nursing program.

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    This document is a surgical scrub form from the University of Perpetual Help System - GMA Campus. It contains fields for the student's name and signature, date and time of the procedure, patient information, procedure performed, supervising nurse and clinical instructor signatures. The form also documents approvals from the chief nurse, clinical coordinator and dean of the nursing program.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    10 views2 pages

    Surgical Scrub Minor

    Uploaded by

    nipsnips
    This document is a surgical scrub form from the University of Perpetual Help System - GMA Campus. It contains fields for the student's name and signature, date and time of the procedure, patient information, procedure performed, supervising nurse and clinical instructor signatures. The form also documents approvals from the chief nurse, clinical coordinator and dean of the nursing program.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    of 2

    UNIVERSITY OF PERPETUAL HELP SYSTEM - GMA CAMPUS

    ODC Form 2 ACTUAL DELIVERY

    BRGY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE PHONE # (02) 490-7748, FAX # (046) 890-1393, Email Add: uphsgma nursing@yahoo.com, Website: uphsl.edu.ph SURGICAL SCRUB in ________________________________________ (Minor) Hospital, Municipal/City/Province
    Prepared by: Name of Student________________________ Signature of Student ___________________________

    Date Performed and Time Started

    Patients Name Case Number


    (Not Applicable for Birthing/Lying-In Clinics/Homes)

    PROCEDURE PERFORMED

    D.R. Nurse On Duty (Name only)

    SUPERVISED BY Clinical Instructor Name and signature

    Noted by: Chief Nurse


    PRC I.D. No. 0174923 Valid Until July 12, 2012 5, 2011 PNA No. 2011 047209 Valid Until Oct. 31, 2011 31, 2011 Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Master of Arts in Nursing Arts in Nursing

    Concurred by:

    JONATHAN R. YANEZA, RN, MAN Clinical Coordinator


    PRC I.D No. PNA No. 0295145 2011- 042203 Valid Until Valid Until August October

    Date document is signed: Time Please specify Highest Nursing Degree Earned: Master of

    Approved by: PRC I.D No. ADPCN No. 114856 0399 Valid Until Valid Until

    Ma. Vilma Bautista, RN, MAN Dean November 2013 PNA No. 10134 April 2011 Date document is signed:

    Valid until Time

    Lifetime

    Please specify Highest Nursing Degree Earned:

    Master of Arts in Nursing

    For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN

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