BATAAN PENINSULA STATE UNIVERSITY

COLLEGE OF NURSING AND MIDWIFERY

Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph

Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
Level: 3
Date of Accreditation: January 01, 2014
ICNB Form
IMMEDIATE CARE OF THE NEWBORN
SURGICAL SCRUB IN Bataan General Hospital, City of Balanga, Bataan FORM
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student: VISTO, MARGARETTE FAYE ORCENA
(Printed Name & Signature of Student)

Date Performed Patients INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BY
and Case Number PERFORMED (Name & Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-In, Clinics/Homes Indicate where performed e.g. D.R., Nursery, NICU, or Home (If Midwife on Duty, Signature not required) Name & Signature

August 11, 2014

01:19PM
21-76-53 | I.M.C. (Girl Celestial) Delivery Room
Marianne G. Javines, RN Norma R. Pantaleon, MAN
August 12, 2014
09:10PM
21-76-79 | G.P. (Boy Pizarro) Delivery Room
Rechelle Ann M. Yuson, RN Norma R. Pantaleon, MAN
August 12, 2014
01:17PM
21-76-88 | A.F.P. (Boy Pajarin) Delivery Room
Rechelle Ann M. Yuson, RN Norma R. Pantaleon, MAN
January 09, 2015
01:31PM
22-44-96 | R.V. (Girl Vallecera) Delivery Room
Kimberly Ann D. Yabut, RN Rachel D. Castillo, MAN
January 22, 2015
07:54AM
22-50-01 | K.T. (Boy Tagara) NICU
Marianne G. Javines, RN Rachel D. Castillo, MAN

Noted by: Concurred: Approved by:

JOCELYN FAUSTINO VILLANUEVA, RN, Ed.D EVELYN ROBLES RUBIA, RN, MAN, PhD RUBY SANTOS MATIBAG, RM, RN, Ed.D
Clinical Coordinator Chief Nurse Dean
PRC I.D. no: 0177589 PRC I.D. no: 0098006 PRC I.D. no: 0285929 / 0142873
Valid until: JUNE 27, 2018 Valid until: OCTOBER 22, 2020 Valid until: FEBRUARY 26, 2019
PNA no: 16170 PNA no: 7845 PNA no: 2017-024738
Valid until: LIFETIME Valid until: LIFETIME Valid until: DECEMBER 31, 2017
Date document is signed: Date document is signed: Date document is signed:
Highest degree earned: DOCTOR OF EDUCATION Highest degree earned: DOCTOR OF PHILOSOPHY Highest degree earned: DOCTOR OF EDUCATION
 BATAAN PENINSULA STATE UNIVERSITY
COLLEGE OF NURSING AND MIDWIFERY
Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph

Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
Level: 3
Date of Accreditation: January 01, 2014
D.R. Form
SURGICAL CIRCULATING IN Bataan General Hospital, City of Balanga, Bataan ACTUAL DELIVERY HANDLED
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student: VISTO, MARGARETTE FAYE ORCENA
(Printed Name & Signature of Student)

Date Performed Patients INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and Case Number PERFORMED (Name & Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-In, Clinics/Homes (If Midwife on Duty, Signature not required) Name & Signature

August 18, 2014

11:19AM
11-87-33 | K.D.C. Normal Spontaneous Delivery
Annalyn D. Ilustre, RN Ruby S. Matibag, RN, Ed.D
August 19, 2014
08:32AM
21-79-90 | R.A.C. Normal Spontaneous Delivery
Annalyn D. Ilustre, RN Ruby S. Matibag, RN, Ed.D
January 08, 2015
02:49PM
22-44-79 | R.J.S. Normal Spontaneous Delivery Beatriz Herminia R. Ilaya, RN Ma. Elinor S. Soriano, MAN
January 22, 2015
10:20AM
22-50-51 | B.T.B. Normal Spontaneous Delivery April D. Bacala, RN Ma. Elinor S. Soriano, MAN
January 22, 2015
12:24PM
16-56-60 | J.A. Normal Spontaneous Delivery April D. Bacala, RN Ma. Elinor S. Soriano, MAN

Noted by: Concurred: Approved by:

JOCELYN FAUSTINO VILLANUEVA, RN, Ed.D EVELYN ROBLES RUBIA, RN, MAN, PhD RUBY SANTOS MATIBAG, RM, RN, Ed.D
Clinical Coordinator Chief Nurse Dean
PRC I.D. no: 0177589 PRC I.D. no: 0098006 PRC I.D. no: 0285929 / 0142873
Valid until: JUNE 27, 2018 Valid until: OCTOBER 22, 2020 Valid until: FEBRUARY 26, 2019
PNA no: 16170 PNA no: 7845 PNA no: 2017-024738
Valid until: LIFETIME Valid until: LIFETIME Valid until: DECEMBER 31, 2017
Date document is signed: Date document is signed: Date document is signed:
Highest degree earned: DOCTOR OF EDUCATION Highest degree earned: DOCTOR OF PHILOSOPHY Highest degree earned: DOCTOR OF EDUCATION
 BATAAN PENINSULA STATE UNIVERSITY
COLLEGE OF NURSING AND MIDWIFERY
Don Manuel Banzon Avenue, City of Balanga, Bataan
(047) 237-5477, mail@bpsu.edu.ph

Accredited by: ACCREDITING AGENCY OF CHARTERED COLLEGES & UNIVERSITIES IN THE PHILIPPINES, INC. (AACCUP)
Level: 3
Date of Accreditation: January 01, 2014
D. R. Form
ACTUAL DELIVERY ASSISTED
SURGICAL SCRUB IN Bataan General Hospital, City of Balanga, Bataan
(Hospital / Home / Lying In Clinic, Municipality / City / Province)
Prepared by:
Name of Student: VISTO, MARGARETTE FAYE ORCENA
(Printed Name & Signature of Student)

Date Performed Patients INITIAL Only PROCEDURE D.R. Nurse on Duty SUPERVISED BY
and Case Number PERFORMED (Name & Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-In, Clinics/Homes (If Midwife on Duty, Signature not required) Name & Signature

August 18, 2014

10:12AM
21-79-43 | R.B. Normal Spontaneous Delivery
Jennylyn M. Mallari, RN Ruby S. Matibag, RN, Ed.D
August 19, 2014
08:50AM
21-79-92 | A.M. Normal Spontaneous Delivery
Jennylyn M. Mallari, RN Ruby S. Matibag, RN, Ed.D
January 08, 2015
02:08PM
22-36-57 | R.T. Normal Spontaneous Delivery Annalyn D. Ilustre, RN Ma. Elinor S. Soriano, MAN
January 08, 2015
03:44PM
22-37-81 | J.C. Normal Spontaneous Delivery Annalyn D. Ilustre, RN Ma. Elinor S. Soriano, MAN
January 23, 2015
07:26AM
20-90-03 | C.M. Normal Spontaneous Delivery April D. Bacala, RN Ma. Elinor S. Soriano, MAN

Noted by: Concurred: Approved by:

JOCELYN FAUSTINO VILLANUEVA, RN, Ed.D EVELYN ROBLES RUBIA, RN, MAN, PhD RUBY SANTOS MATIBAG, RM, RN, Ed.D
Clinical Coordinator Chief Nurse Dean
PRC I.D. no: 0177589 PRC I.D. no: 0098006 PRC I.D. no: 0285929 / 0142873
Valid until: JUNE 27, 2018 Valid until: OCTOBER 22, 2020 Valid until: FEBRUARY 26, 2019
PNA no: 16170 PNA no: 7845 PNA no: 2017-024738
Valid until: LIFETIME Valid until: LIFETIME Valid until: DECEMBER 31, 2017
Date document is signed: Date document is signed: Date document is signed:
Highest degree earned: DOCTOR OF EDUCATION Highest degree earned: DOCTOR OF PHILOSOPHY Highest degree earned: DOCTOR OF EDUCATION