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WESTERN MINDANAO STATE UNIVERSITY

COLLEGE OF NURSING
Zamboanga City
Name of Student:
Yr. Level: ________________________________________

Rotation No. & Date: ______________________________


Hospital & Area of Assignment: _____________________

SURGICAL SCRUB CASE


Date
Performe
d
and
Time
Started

Patients INITIALS
(only)
Case Number

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On
Duty
(Name and
Signature)

Noted by:
MA. LOURDES M. WEE SIT, R.N., M.N.
Clinical Coordinator
WESTERN MINDANAO STATE UNIVERSITY

SUPERVISED BY:
Clinical Instructor
(Name and
Signature)

COLLEGE OF NURSING
Zamboanga City
Name of Student:
Yr. Level: ________________________________________

Rotation No. & Date: ______________________________


Hospital & Area of Assignment: _____________________

SURGICAL CIRCULATING CASE


Date
Performed
and
Time
Started

Patients INITIALS
(only)
Case Number

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On
Duty
(Name and
Signature)

Noted by:
MA. LOURDES M. WEE SIT, R.N., M.N.
Clinical Coordinator

SUPERVISED BY:
Clinical Instructor
(Name and
Signature)

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