MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: AmaiPakpak Medical Center, Marawi City, Lanao del Sur
Hospital/Home/Lying-in, Municipality/City/Province

ODC Form 1A
ACTUAL DELIVERY
FORM

Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)

PROCEDURE PERFORMED

January 15, 2012

4:50 PM

R. G.
14-11-51

Normal Spontaneous Vaginal Delivery

March 7, 2013
5:10 PM

R. M.
14-66-59

Normal Spontaneous Vaginal Delivery

H. I.
09-73-87

Normal Spontaneous Vaginal Delivery

March 9, 2013
10:05 PM

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________

(NSVD)

(NSVD)

(NSVD)

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty, Signature
Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Emily M. Abbas
PRC Number: 0709999
Valid Until:

Shiennah O. Lunag, RN
PRC Number: 0545623
Valid Until: March 13, 2015

Farida Lawa, RN
PRC Number:
Valid Until:

Shiennah O. Lunag, RN
PRC Number: 0545623
Valid Until: March 13, 2015

Farida Lawa, RN
PRC Number:
Valid Until:

Shiennah O. Lunag, RN
PRC Number: 0545623
Valid Until: March 13, 2015

Valid Until: March 17, 2016

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Time: __________________

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned:

Arts in Nursing_____

_______________________

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
SURGICAL SCRUB in: AmaiPakpak Medical Center, Marawi City, Lanao del Sur
Hospital/Home/Lying-in, Municipality/City/ Province

ODC Form 2A
O.R. SCRUB FORM
Major

Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

SURGICAL PROCEDURE
PERFORMED

September 28,
2011
12:40 AM

N. B. B.
10-94-93

Appendectomy Lavage

October 2, 2011
10:06 PM

A. L. G.
10-94-93

Repeat Cesarean Section

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________

O.R. Nurse on Duty

(Name and Signature)

June Michael Claret, RN

PRC Number: 0410256

Valid Until:
K. Firmo, RN

PRC Number:
Valid Until:

SUPERVISED BY
Clinical Instructor
Name and Signature

Albert Dan Mero, RN

PRC Number:
Valid Until:
Albert Dan Mero, RN
PRC Number:
Valid Until:

Valid Until: March 17, 2016

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Time: __________________

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned:

Arts in Nursing_____

_______________________

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
SURGICAL SCRUB in: Gregorio T. Lluch Memorial Hospital, Iligan City, Lanao del Norte
Hospital/Home/Lying-in, Municipality/City/ Province

ODC Form 2A
O.R. SCRUB FORM
Major

Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA

Date Performed
and
Time Started

January 11, 3013

6:55 PM

Patients INITIALS (only)

Case Number

SURGICAL PROCEDURE
PERFORMED

C. S. D.
16-31-71

Explore Laparotomy +
Salphingectomy L

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364 Valid Until: March 17, 2016
September 21, 2015
Date document is signed: _______________ Time: __________________
_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____

O.R. Nurse on Duty

(Name and Signature)

Francis Padilla, RN
PRC Number: 0629394
Valid Until:

SUPERVISED BY
Clinical Instructor
Name and Signature

Nur-in D. Binudin, RN, MAN

PRC Number:
Valid Until:

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: Lanao Del Norte Provincial Hospital
Hospital/Home/Lying-in, Municipality/City/Province

ODC Form 1C
CORD CARE FORM

Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA
Patients INITIALS (only)
Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)

Immediate Newborn Cord Care

PERFOMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty, Signature
Not Required)

March 22, 2011

7:30 AM

Baby Boy A.
03-38-70

Cord Care
Neonatal Intensive Care Unit (NICU)

Vilma Alvia, RN
PRC Number:
Valid Until:

Julius Mirafuentes, RN, MN,

MAN
PRC Number: 0298656
Valid Until: November 2, 2015

February 01, 2012

2:15 AM

Baby Girl S.
03-38-48

Cord Care
Neonatal Intensive Care Unit (NICU)

Vilma Alvia, RN
PRC Number:
Valid Until:

Julius Mirafuentes, RN, MN,

MAN
PRC Number: 0298656
Valid Until:

Date Performed
and
Time Started

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015

Valid Until: March 17, 2016

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Date document is signed: _______________ Time: __________________

_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: AmaiPakpak Medical Center, Marawi City, Lanao del Sur
Hospital/Home/Lying-in, Municipality/City/Province

ODC Form 1C
CORD CARE FORM

Prepared by:
Printed Name and Signature of Student: NORAIN TAC-AN BUNSA

Date Performed
and
Time Started

January 17, 2013

12:42 PM

Patients INITIALS (only)

Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)

Immediate Newborn Cord Care

PERFOMED
Indicate where performed e.g. D.R.,
Nursery, NICU, or Home

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty, Signature
Not Required)

Baby Boy M.
14-16-95

Cord Care
Neonatal Intensive Care Unit (NICU)

Lovely Ann Olis, RN

PRC Number: 0723059
Valid Until:

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015

Valid Until: March 17, 2016

SUPERVISED BY
Clinical Instructor
Name and Signature

Shiennah O. Lunag
PRC Number: 0545623
Valid Until: March 13, 2015

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Date document is signed: _______________ Time: __________________

_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned: Master of