M T

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ST. THERESE-MTC COLLEGES

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L L E G E S
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La Fiesta Site

T .
M.H. Del Pilar Street, Molo, Iloilo City, Philippines

S
Tel Nos. (033) 336-1408 Fax No. (033) 337-9508
Email: lafiesta_hotel@yahoo.com.ph

Specified Forms and Scrubs As Per PRC Resolution No. 357 Series 2004 and PRC-BON Memorandum No. 01, Series 2008
School : ST. THERESE - MTC COLLEGES, LA FIESTA SITE ______
Address: M.H. DEL PILAR STREET, MOLO, ILOILO CITY
Name of Student: Elke D. de Sullan ______First Course (If Any): N/A Year: N/A
Date School/Program was Recognized School Graduated from: N/A________ _ ___________ _
Accreditation Level: N/A Year of Admission in the BSN Program: 2005
Year Graduated from the BSN Program: 2010

I. MAJOR OPERATIONS

No. Time Time Date of Case No. Name of Patient Operation Performed Type of Name of Surgeon Name of Hospital
Started Ended Operation Anesthesia

1. September Spinal
Dr. Acana
8:15AM 9:55AM 101442 Lagat, Ligaya St. Therese - MTC Colleges Hospital
19, 2009 Anesthesia

Spinal
4:00PM 101553 Mohamad, Barbara Mae Dr. Flores St. Therese - MTC Colleges Hospital
2. Anesthesia

Prepared by:
_____ELKE D. DE SULLAN________________________
Signature over Printed Name of
Student
Supervised by: Noted by: Concurred by: Approved by:

__ROSA BEDIA, RN___________
Signature over Printed Name of
Clinical Instructor
Date Signed: ______________________
Degree: ______________________
a) PRC No.: ______________________
Valid Until: ______________________
b) PNA No.: ______________________
Valid Until: ______________________
_NANCY G. BASCO, R.N., M.A.N. MA. ELOSIA S. PENADO R.N., M.A.N._ NERISSA D. DE ASIS, R.N., M.A.N.
Signature over Printed Name of Signature over Printed Name of the Signature over Printed Name of the
Clinical Coordinator Chief Nurse Dean
Date Signed: _______________________ Date Signed: _______________________ Date Signed: _______________________
Degree: B.S.N, M.A.N.______ _ ___ Degree: B.S.N., M.A.N.________ _ Degree: B.S.N., M.A.N._______ _
a) PRC No.: 0115477________________ a) PRC No.: 0127939________________ a) PRC No.: 31124__________________
Valid Until: September 10, 2012_______ Valid Until: February 11, 2013______ _ Valid Until: _______________________
b) PNA No.: 089833_________________ b) PNA No.: _______________________ b) PNA No.: 048615_________________
Valid Until: October 31, 2010_________ Valid Until: _______________________ Valid Until: LIFETIME MEMBERSHIP_
ADPCN No.: 0668 ____ __
Valid Until: 2010
 M T
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ST. THERESE-MTC COLLEGES

E C

C
O
E

L L E G E S
T H
La Fiesta Site

T .
M.H. Del Pilar Street, Molo, Iloilo City, Philippines

S
Tel Nos. (033) 336-1408 Fax No. (033) 337-9508
Email: lafiesta_hotel@yahoo.com.ph
Specified Forms and Scrubs As Per PRC Resolution No. 357 Series 2004 and PRC-BON Memorandum No. 01, Series 2008
School : ST. THERESE - MTC COLLEGES, LA FIESTA SITE ______
Address: M.H. DEL PILAR STREET, MOLO, ILOILO CITY
Name of Student: Elke D. de Sullan ______First Course (If Any): N/A Year: N/A
Date School/Program was Recognized School Graduated from: N/A________ _ ___________ _
Accreditation Level: N/A Year of Admission in the BSN Program: 2005
Year Graduated from the BSN Program: 2010

I. MINOR OPERATIONS

No. Time Time Date of Case No. Name of Patient Operation Performed Type of Name of Surgeon Name of Hospital
Started Ended Operation Anesthesia

1. 8:00AM 10:30 October 3, 101612 Gregori, Janet Excision of Sebaceous Cyrt, Nape Local Dr. Santacera St. Therese - MTC Colleges Hospital
AM 2009 Anesthesia

Prepared by:
_____ELKE D. DE SULLAN_________
Signature over Printed Name of
Student
Supervised by: Noted by: Concurred by: Approved by:

___ROSA BEDIA, RN___________
Signature over Printed Name of
Clinical Instructor
Date Signed: ______________________
Degree: ______________________
a) PRC No.: ______________________
Valid Until: ______________________
b) PNA No.: ______________________
Valid Until: ______________________
NANCY G. BASCO, R.N., M.A.N. MA. ELOSIA S. PENADO R.N., M.A.N._ NERISSA D. DE ASIS, R.N., M.A.N.
Signature over Printed Name of Signature over Printed Name of the Signature over Printed Name of the
Clinical Coordinator Chief Nurse Dean
Date Signed: _______________________ Date Signed: _______________________ Date Signed: _______________________
Degree: B.S.N, M.A.N.______ _ ___ Degree: B.S.N., M.A.N.________ _ Degree: B.S.N., M.A.N._______ _
a) PRC No.: 0115477________________ a) PRC No.: 0127939________________ a) PRC No.: 31124__________________
Valid Until: September 10, 2012_______ Valid Until: February 11, 2013______ _ Valid Until: _______________________
b) PNA No.: 089833_________________ b) PNA No.: _______________________ b) PNA No.: 048615_________________
Valid Until: October 31, 2010_________ Valid Until: _______________________ Valid Until: LIFETIME MEMBERSHIP__
ADPCN No.: 0668 ____ __
Valid Until: 2010 _
 M T
S E

ST. THERESE-MTC COLLEGES

E C

C
O
E

L L E G E S
T H
La Fiesta Site

T .
M.H. Del Pilar Street, Molo, Iloilo City, Philippines

S
Tel Nos. (033) 336-1408 Fax No. (033) 337-9508
Email: lafiesta_hotel@yahoo.com.ph

Specified Forms and Scrubs As Per PRC Resolution No. 357 Series 2004 and PRC-BON Memorandum No. 01, Series 2008
School : ST. THERESE - MTC COLLEGES, LA FIESTA SITE _______
Address: M.H. DEL PILAR STREET, MOLO, ILOILO CITY _
Name of Student: Elke D. de Sullan ______First Course (If Any): N/A Year: N/A _
Date School/Program was Recognized School Graduated from: N/A________ _ ___________ __
Accreditation Level: N/A Year of Admission in the BSN Program: 2005 _
Year Graduated from the BSN Program: 2010 _

I. ACTUAL DELIVERIES

No. Case Diagnosis Name of Mother Age Date of Time of Gender Name of Hospital Type of Delivery
No. Delivery delivery of Baby
1. Pregnancy Uterine delivered to a live 38
Baby Boy in cephalic presentation via Eresma, Analiza. November 4:36PM Male St. Therese – MTC Colleges Hospital Normal Spontaneous Vaginal Delivery
101995
Normal Spontaneous Vaginal Delivery 16, 2009
G2P2 (2002)
2. Pregnancy Uterine Full Term delivered
102209 to a live Baby Girl via Normal Suarez, Madonna December 8:13PM Female St. Therese – MTC Colleges Hospital Normal Spontaneous Vaginal Delivery
Spontaneous Vaginal Delivery Apgar 15, 2009
Score 8/10 PROM 4H G3P2 (2012)
3. Pregnancy Uterine delivered via
102208 Normal Spontaneous Vaginal Delivery Pacliban, Corazon December 10:59PM Female St. Therese – MTC Colleges Hospital Normal Spontaneous Vaginal Delivery
to a live Baby Girl G5P5 (5004) 15, 2009

Prepared by:
____ELKE D. DE SULLAN__________
Signature over Printed Name of
Student
Supervised by: Noted by: Concurred by: Approved by:

__MA. CORAZON LEE, RN_____
Signature over Printed Name of
Clinical Instructor
Date Signed: ______________________
Degree: ______________________
a) PRC No.: ______________________
Valid Until: ______________________
b) PNA No.: ______________________
Valid Until: ______________________
_NANCY G. BASCO, R.N., M.A.N. MA. ELOSIA S. PENADO R.N., M.A.N._ NERISSA D. DE ASIS, R.N., M.A.N. _
Signature over Printed Name of Signature over Printed Name of the Signature over Printed Name of the
Clinical Coordinator Chief Nurse Dean
Date Signed: _______________________ Date Signed: _______________________ Date Signed: _______________________
Degree: B.S.N, M.A.N.______ _ ___ Degree: B.S.N., M.A.N.________ _ Degree: B.S.N., M.A.N._______ _
a) PRC No.: 0115477________________ a) PRC No.: 0127939________________ a) PRC No.: 31124__________________
Valid Until: September 10, 2012_______ Valid Until: February 11, 2013______ _ Valid Until: _______________________
b) PNA No.: 089833_________________ b) PNA No.: _______________________ b) PNA No.: 048615_________________
Valid Until: October 31, 2010_________ Valid Until: _______________________ Valid Until: LIFETIME MEMBERSHIP__
ADPCN No.: 0668 ____ __
Valid Until: 2010 _
 M T
S E

ST. THERESE-MTC COLLEGES

E C

C
O
E

L L E G E S
T H
La Fiesta Site

T .
M.H. Del Pilar Street, Molo, Iloilo City, Philippines

S
Tel Nos. (033) 336-1408 Fax No. (033) 337-9508
Email: lafiesta_hotel@yahoo.com.ph

Specified Forms and Scrubs As Per PRC Resolution No. 357 Series 2004 and PRC-BON Memorandum No. 01, Series 2008
School : ST. THERESE - MTC COLLEGES, LA FIESTA SITE ______
Address: M.H. DEL PILAR STREET, MOLO, ILOILO CITY
Name of Student: Elke D. de Sullan ______First Course (If Any): N/A Year: N/A
Date School/Program was Recognized School Graduated from: N/A________ _ ___________ _
Accreditation Level: N/A Year of Admission in the BSN Program: 2005
Year Graduated from the BSN Program: 2010

I.DELIVERIES ASSISTED

No. Case No. Diagnosis Name of mother Age Date of Time of Gender Name of Hospital Type of Delivery
Delivery delivery of
Baby
Prepared by:

1. __
005528 Delgado, Marites 35 November 1:19PM Female St. Therese – MTC Colleges Hospital Normal Spontaneous Vaginal Delivery ___ELKE D.
9, 2009

2. Pregnancy Uterine Full Term delivered April 13, 12:18AM Male St. Therese – MTC Colleges Hospital
via Normal Spontaneous Vaginal 2010
104073 Delivery to a live Baby Girl in cephalic Valenzuela, Maricel 30 Normal Spontaneous Vaginal Delivery
presentation; weight 3.5kgs.
DESULLAN__________
Signature over Printed Name of
Student
Supervised by: Noted by: Concurred by: Approved by:

____ROSA BEDIA, RN_________
Signature over Printed Name of
Clinical Instructor
Date Signed: ______________________
Degree: ______________________
a) PRC No.: ______________________
Valid Until: ______________________
b) PNA No.: ______________________
Valid Until: ______________________
_NANCY G. BASCO, R.N., M.A.N. MA. ELOSIA S. PENADO R.N., M.A.N._ NERISSA D. DE ASIS, R.N., M.A.N.
Signature over Printed Name of Signature over Printed Name of the Signature over Printed Name of the
Clinical Coordinator Chief Nurse Dean
Date Signed: _______________________ Date Signed: _______________________ Date Signed: _______________________
Degree: B.S.N, M.A.N.______ _ ___ Degree: B.S.N., M.A.N.________ _ Degree: B.S.N., M.A.N._______ _
a) PRC No.: 0115477________________ a) PRC No.: 0127939________________ a) PRC No.: 31124__________________
Valid Until: September 10, 2012_______ Valid Until: February 11, 2013______ _ Valid Until: _______________________
b) PNA No.: 089833_________________ b) PNA No.: _______________________ b) PNA No.: 048615_________________
Valid Until: October 31, 2010_________ Valid Until: _______________________ Valid Until: LIFETIME MEMBERSHIP__
ADPCN No.: 0668 ____ __
Valid Until: 2010
M T
S E

ST. THERESE-MTC COLLEGES

E C
R

C
O
E

L L E G E S
T H
T .
S
 La Fiesta Site
M.H. Del Pilar Street, Molo, Iloilo City, Philippines
Tel Nos. (033) 336-1408 Fax No. (033) 337-9508
Email: lafiesta_hotel@yahoo.com.ph

Specified Forms and Scrubs As Per PRC Resolution No. 357 Series 2004 and PRC-BON Memorandum No. 01, Series 2008
School : ST. THERESE - MTC COLLEGES, LA FIESTA SITE ______
Address: M.H. DEL PILAR STREET, MOLO, ILOILO CITY
Name of Student: Elke D. de Sullan ______First Course (If Any): N/A Year: N/A
Date School/Program was Recognized School Graduated from: N/A________ _ ___________ _
Accreditation Level: N/A Year of Admission in the BSN Program: 2005
Year Graduated from the BSN Program: 2010

I. CORD DRESSING

No. Case No. Date Performed Time of delivery Gender of Baby Name of Mother Age Name of Hospital

September 21, 2009 1:41PM Female Guitche, April 23 St. Therese – MTC Colleges Hospital
1. 101502

2. 101855 October 4, 2009 3:50PM Female Mondejar, Ma. Elizabeth 35 St. Therese – MTC Colleges Hospital

Prepared by:
______ELKE D. DE SULLAN_______
Signature over Printed Name of
Student
Supervised by: Noted by: Concurred by: Approved by:

____ROSA BEDIA, RN__________ _NANCY G. BASCO, R.N., M.A.N. MA. ELOSIA S. PENADO R.N., M.A.N._ NERISSA D. DE ASIS, R.N., M.A.N.
Signature over Printed Name of Signature over Printed Name of Signature over Printed Name of the Signature over Printed Name of the
Clinical Instructor Clinical Coordinator Chief Nurse Dean
Date Signed: ______________________ Date Signed: _______________________ Date Signed: ________________________ Date Signed: _______________________
Degree: ______________________ Degree: B.S.N, M.A.N.______ _ ___ Degree: B.S.N., M.A.N.________ _ _ Degree: B.S.N., M.A.N._______ _
a) PRC No.: ______________________ a) PRC No.: 0115477________________ a) PRC No.: 0127939_________________ a) PRC No.: 31124__________________
Valid Until: ______________________ Valid Until: September 10, 2012_______ Valid Until: February 11, 2013______ __ Valid Until: _______________________
b) PNA No.: ______________________ b) PNA No.: 089833_________________ b) PNA No.: ________________________ b) PNA No.: 048615_________________
Valid Until: ______________________ Valid Until: October 31, 2010_________ Valid Until: ________________________ Valid Until: LIFETIME MEMBERSHIP__
ADPCN No.: 0668 ____ __
Valid Until: 2010 _