DE LA SALLE LIPA

COLLEGE OF NURSING

Name of Student: Raisa Stella B. Landicho

Name & Address of School: 1962 J.P. Laurel National Highway, Lipa City, 4217 Batangas
Accreditation Level (if any) ___________ Year Granted _______________
Date School /Program was recognized: ____________ Number: ________ Year: _______
First Course (if any): _________________ School Graduated From: _______ Year: _____
Year of Admission in Bachelor of Science in Nursing: SY 2005 – 2006
Year Graduated (BSN Program): _____________

I. Major Operations
No Date of Case No. Name of Patient Diagnosis Operation Type of Name of Surgeon Name of Hospital Name of O.R. Signature
Operation Performed Anesthesia Scrub Nurse of O.R.
Scrub
Nurse
1 August 27, 108777 Laila Bolor Gravida1 Para0 35 Caesarian Section Spinal Dra. Ellen Diga Mary Mediatrix Medical
2008 weeks, Cephalic in Center
Labor, Fetal
Anencephaly,
Polyhydramnios
2 September 108937 Venus Reña Septic Knee Arthrotomy and Spinal Dr. Villanueva Mary Mediatrix Medical
13,2008 Synovectomy Center
3 December 109412 Felipe Caraan Benign Prostatic Trans-urethral Spinal Dr.Songco Mary Mediatrix Medical
11, 2008 Hyperplasia Resection of the Center
Prostate
4
5
Prepared by:

_________________________________
Student’s Signature over Printed Name
Supervised by: Noted by: Concurred by: Approved by:

_______________________________ _______________________________ _______________________________ _______________________________

Faculty’s Signature over Printed Name
Date Signed: ___________
Degree : _______________
a) PRC No.: ____________
Valid Until : _________
b) PNA No.: ____________
Valid Until : _________
Signature of Clinical Coordinator Signature of Chief Nurse Signature of Dean
over Printed Name over Printed Name over Printed Name
Date Signed: ___________ Date Signed: ___________ Date Signed: ___________
Degree : _______________ Degree : _______________ 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) ADPCN No.: ____________
Valid Until : ___________
DE LA SALLE LIPA
 COLLEGE OF NURSING

Name of Student: Raisa Stella B. Landicho

Name & Address of School: 1962 J.P. Laurel National Highway, Lipa City, 4217 Batangas
Accreditation Level (if any) ___________ Year Granted _______________
Date School /Program was recognized: ____________ Number: ________ Year: _______
First Course (if any): _________________ School Graduated From: _______ Year: _____
Year of Admission in Bachelor of Science in Nursing: SY 2005 – 2006
Year Graduated (BSN Program): _____________

I. Major Operations
No Date of Case No. Name of Patient Diagnosis Operation Type of Name of Surgeon Name of Hospital Name of O.R. Signature
Operation Performed Anesthesia Scrub Nurse of O.R.
Scrub
Nurse
1 April 12903 Teresita Dela Rosa Cholelithiasis Cholecystectomy Spinal Dr. De Castro Lipa Medix Medical Rosalinda J.
2,2007 Center Jopia RN, MAN
2 February 21420 Mylen Babadilla Pregnancy Uterine Caesarian Section Spinal Dra. Helen Comia Lipa Medix Medical Rosalinda J.
5,2008 39-40 weeks Center Jopia RN, MAN
Gravida1Para0
3
4
5
Prepared by:

_________________________________
Student’s Signature over Printed Name
Supervised by: Noted by: Concurred by: Approved by:

_______________________________ _______________________________ _______________________________ _______________________________

Faculty’s Signature over Printed Name
Date Signed: ___________
Degree : _______________
c) PRC No.: ____________
Valid Until : _________
d) PNA No.: ____________
Valid Until : _________
Signature of Clinical Coordinator Signature of Chief Nurse Signature of Dean
over Printed Name over Printed Name over Printed Name
Date Signed: ___________ Date Signed: ___________ Date Signed: ___________
Degree : _______________ Degree : _______________ Degree : _______________
c) PRC No.: ____________ c) PRC No.: ____________ d) PRC No.: ____________
Valid Until : _________ Valid Until : _________ Valid Until : _________
d) PNA No.: ____________ d) PNA No.: ____________ e) PNA No
Valid Until : _________ Valid Until : _________ Valid Until : _________
f) ADPCN No.: ____________
Valid Until : ___________