ODC Form 2A

Universidad de Sta. Isabel O.R. SCRUB FORM

City of Naga, Philippines Major
College of Nursing
Tel. No. 473-84-17 . 473-8442 local 219. Fax No. 472-28-71
www.usi.edu.ph . usi_webteam@yahoo.com
PAASCU Level II Re-Accredited, 2007-2012

SURGICAL SCRUB in Universidad de Sta. Isabel-Health Services Department, Naga City, Camarines Sur.
Hospital, Municipality/City/Province
Prepared by:
Printed Name of Student CARLOS D. ACHONDO JR.

Date Performed SUPERVISED BY

Patient’s INITIALS (only)
SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature
AA Exlap, Adhesiolysis, ileostomy
August 22, 2016 869-92-869 Fe A. Encilia, RN Mrs. Lyn de Leon, RN, MAN
9:50 AM
PCE Above Knee Amputation, Left
January 11, Fe A. Encilla, RN Mrs. Lyn de Leon, RN MAN
2016 780-42-780
12:47 PM
January 16, CD Primary Low Transverse Cesarean Section
2016 Fe A. Encilla, RN Mrs. Lyn de Leon, RN, MAN
2:40 PM 892-34-892

Noted by: GLENDA C. ICARO, R.N., MAN, Ph.D. Approved by: MRS. SALVE T. ZUÑIGA, R.N., MAN
( Print Name and Signature ) ( Print Name and Signature )
Clinical Coordinator, PRC I.D No.0226312 Valid Until ___Dec. 20, 2018 Dean, PRC I.D No. 0097638 Valid Until July 13, 2018
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN
 ODC Form 2B
Universidad de Sta. Isabel O.R. CIRCULATING
City of Naga, Philippines FORM
College of Nursing
Tel. No. 473-84-17 . 473-8442 local 219. Fax No. 472-28-71
www.usi.edu.ph . usi_webteam@yahoo.com
PAASCU Level II Re-Accredited, 2007-2012

CIRCULATING NURSE In USI HEALTH Services Department, Naga City, Cam Sur
Hospital, Municipality/City/Province

Prepared by:
Printed Name of Student CARLOS D. ACHONDO JR.

Date Performed SUPERVISED BY

Patient’s INITIALS (only)
SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature
FB Exlap; Gastrojejunostomy; Reux ENY; Mesenteric Node Biopsy
January 14, 848-93-848 Fe A. Encilla, RN Mrs. Lyn de Leon, RN, MAN
2017
2:08 PM
FC Throidectomy with Frozen Section
February 14, Fe A. Encilla, RN Mrs. Lyn de Leon, RN, MAN
2017
3:29 PM

Noted by: GLENDA C. ICARO, R.N., MAN, Ph.D. Approved by: MRS. SALVE T. ZUÑIGA, R.N., MAN
( Print Name and Signature ) ( Print Name and Signature )
Clinical Coordinator, PRC I.D No.0226312 Valid Until ___Dec. 20, 2018 Dean, PRC I.D No. 0097638 Valid Until July 13, 2018
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN
 Universidad de Sta. Isabel ODC Form 1A
City of Naga, Philippines ACTUAL DELIVERY FORM
College of Nursing
Tel. No. 473-84-17 . 473-8442 local 219. Fax No. 472-28-71
www.usi.edu.ph . usi_webteam@yahoo.com
PAASCU Level II Re-Accredited, 2007-2012

ACTUAL DELIVERY in Bicol Medical Center, Naga City, Camarines Sur

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name of Student CARLOS D. ACHONDO JR.

D.R. Nurse On Duty

Date Performed Patient’s INITIALS (only) SUPERVISED BY
(Name and Signature)
and Case Number (not PROCEDURE PERFORMED (If Midwife on Duty, Signature not
Clinical Instructor
Time Started applicable for Birthing/Lying- Name and Signature
Required)
In Clinics/Homes)
February 17, FMP Normal Spontaneous Delivery
2016 804101 Amie M. Clarete, RN, MAN Rhandy V. Salvani, RN, MAN
1:16 PM

July 25, 2017 CSL Normal Spontaneous Delivery

6:59 AM 892558 Amie M. Clarete, RN, MAN Dr. Agnes D. Solis, RN, MAN

July 25, 2017 MBL Normal Spontaneous Delivery

12:56 PM 619008 Amie M. Clarete, RN, MAN Dr. Agnes D. Solis, RN, MAN

Noted by: GLENDA C. ICARO, R.N., MAN, Ph.D. Approved by: MRS. SALVE T. ZUÑIGA, R.N., MAN
( Print Name and Signature ) ( Print Name and Signature )
Clinical Coordinator, PRC I.D No.0226312 Valid Until ___Dec. 20, 2018 Dean, PRC I.D No. 0097638 Valid Until July 13, 2018
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN
 ODC Form 1B
Universidad de Sta. Isabel ASSISTED DELIVERY FORM
City of Naga, Philippines
College of Nursing
Tel. No. 473-84-17 . 473-8442 local 219. Fax No. 472-28-71
www.usi.edu.ph . usi_webteam@yahoo.com
PAASCU Level II Re-Accredited, 2007-2012

ASSISTED DELIVERY in Bicol Medical Center, Naga City, Camarines Sur

Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name of Student CARLOS D. ACHONDO JR.

D.R. Nurse On Duty

Date Performed Patient’s INITIALS (only) PROCEDURE PERFORMED SUPERVISED BY
(Name and Signature)
and Case Number (not Clinical Instructor
(If Midwife on Duty, Signature not
Time Started applicable for Birthing/Lying- ASSISTED DELIVERY Name and Signature
Required)
In Clinics/Homes)
MAB Assisted Delivery
February 15, 618235 Amie M. Clarete, RN, MAN Rhandy V. Salvani, RN, MAN
2016
4:33 PM
February 15, MGR Assisted Delivery
2016 790016 Amie M. Clarete, RN, MAN Rhandy V. Salvani, RN, MAN
4:57 PM

July 25, 2017 NPG Assisted Delivery

8:10 AM 892543 Amie M. Clarete, RN, MAN Dr. Agnes D. Solis, RN, MAN

Noted by: GLENDA C. ICARO, R.N., MAN, Ph.D. Approved by: MRS. SALVE T. ZUÑIGA, R.N., MAN
( Print Name and Signature ) ( Print Name and Signature )
Clinical Coordinator, PRC I.D No.0226312 Valid Until ___Dec. 20, 2018 Dean, PRC I.D No. 0097638 Valid Until July 13, 2018
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN
 Universidad de Sta. Isabel
City of Naga, Philippines ODC Form 1C
College of Nursing CORD CARE FORM
Tel. No. 473-84-17 . 473-8442 local 219. Fax No. 472-28-71
www.usi.edu.ph . usi_webteam@yahoo.com
PAASCU Level II Re-Accredited, 2007-2012

IMMEDIATE NEWBORN CORD CARE in Bicol Medical Center, Naga City, Camarines Sur
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name of Student CARLOS D. ACHONDO JR.

Nurse On Duty
Date Performed Patient’s INITIALS (only) SUPERVISED BY
Immediate Newborn Cord Care PERFORMED (Name and Signature)
and Case Number (not Clinical Instructor
Indicate where performed e.g. D.R., Nursery, NICU, or Home (If Midwife on Duty, Signature not
Time Started applicable for Birthing/Lying- Name and Signature
Required)
In Clinics/Homes)
February 16, MAR Delivery Room-Cord Dressing Area
2016 804092 Amie M. Clarete, RN, MAN Rhandy V. Salvani, RN, MAN
3:30 PM

February 17, MVS Delivery Room-Cord Dressing Area

2016 804125 Amie M. Clarete, RN, MAN Rhandy V. Salvani, RN, MAN

July 26, 2017 ACR Delivery Room-Cord Dressing Area

8:11 AM 899000 Amie M. Clarete, RN, MAN Dr. Agnes D. Solis, RN, MAN

Noted by: GLENDA C. ICARO, R.N., MAN, Ph.D. Approved by: MRS. SALVE T. ZUÑIGA, R.N., MAN
( Print Name and Signature ) ( Print Name and Signature )
Clinical Coordinator, PRC I.D No.0226312 Valid Until ___Dec. 20, 2018 Dean, PRC I.D No. 0097638 Valid Until July 13, 2018
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN
 Universidad de Sta. Isabel ODC Form 2B
City of Naga, Philippines O.R. CIRCULATING
College of Nursing FORM
Tel. No. 473-84-17 . 473-8442 local 219. Fax No. 472-28-71
www.usi.edu.ph . usi_webteam@yahoo.com
PAASCU Level II Re-Accredited, 2007-2012

CIRCULATING NURSE In Bicol Medical Center, Naga City Cam. Sur

Hospital, Municipality/City/Province

Prepared by:
Printed Name of Student CARLOS D. ACHONDO JR.

Date Performed SUPERVISED BY

Patient’s INITIALS (only)
SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature
AM Low Transverse Cesarean Section
October 3, 2016 841678 Mary Ann Caresosa, RN, MAN Angelica R. Quidoles, RN, MAN
8:20 AM
JAZ Low Transverse Cesarean Section
August 1, 2017 892628 Mary Ann Caresosa, RN, MAN Angelica R. Quidoles, RN, MAN
1:00 PM

August 2, 2017 JLB Appendectomy

4:30 PM 892058 Mary Ann Caresosa, RN, MAN Angelica R. Quidoles, RN, MAN

Noted by: GLENDA C. ICARO, R.N., MAN, Ph.D. Approved by: MRS. SALVE T. ZUÑIGA, R.N., MAN
( Print Name and Signature ) ( Print Name and Signature )
Clinical Coordinator, PRC I.D No.0226312 Valid Until ___Dec. 20, 2018 Dean, PRC I.D No. 0097638 Valid Until July 13, 2018
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN