New PRC Form

BAGUIO CENTRAL UNIVERSITY ODC Form 1
O.R. SCRUB FORM

College of Nursing and School of Midwifery
(MAJOR)
Magsaysay Avenue, Baguio City (074) – 300-5571
SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Name of Student ______________________________________________ Signature of Student
___________________________________
Date Patient’s Name O.R. Nurse On SUPERVISED BY

Performed Case Number PROCEDURE Duty Clinical Instructor
and (Name only) Name and Signature
Time Started PERFORMED
Noted by: GINA L. CASI, RN Concurred by: ______________________________________

Clinical Coordinator, PRC I.D No.: 0237248 Valid Until: February 04, Chief Nurse, PRC I.D No.: Valid Until: -
2012 PNA No.:- Valid Until : -
PNA No.:006559 Valid Until : December 31, 2009 Date signed: ____________ Time signed: __________________
Date signed: ____________ Time signed: __________________ Highest Nursing Degree Earned: ______________________
Highest Nursing Degree Earned: MAN
Approved by: FLORENCE C. CAWAON, Ed.D.

Dean, PRC I.D No. : 0030933 Valid Until: March 1, 2011
PNA No.: 2663 Valid Until : Lifetime
ADPCN No. 0267 Valid Until : December 31, 2009
Date signed: ________________ Time signed: ___________________
Highest Nursing Degree Earned: Master of Arts in Nursing
ODC Form 1 .a
BAGUIO CENTRAL UNIVERSITY O.R. SCRUB FORM
College of Nursing and School of Midwifery (MINOR)
SURGICAL SCRUB in ________________________________________________________________________

Hospital, Municipality/City/Province
Prepared by:
___________________________________
Date Patient’s Name O.R. Nurse On SUPERVISED BY

Performed Case Number PROCEDURE Duty Clinical Instructor
and (Name only) Name and Signature
Time Started PERFORMED


College of Nursing and School of Midwifery ACTUAL DELIVERY
Magsaysay Avenue, Baguio City (074) – 300-5571 FORM
ACTUAL DELIVERY in ________________________________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Name of Student ______________________________________________ Signature of Student _______

___________________________________
Date Patient’s Name PROCEDURE D.R. SUPERVISED BY

Performed PERFORMED Nurse/Midwife Clinical Instructor
and Case Number On Duty Name and Signature
Time Started (not applicable for
Birthing/Lying-In (Name only)
Clinics/Homes)
Concurred by: ______________________________________

Noted by: GINA L. CASI, RN Chief Nurse, PRC I.D No.: Valid Until: -
Clinical Coordinator, PRC I.D No.: 0237248 Valid Until: February 04, PNA No.:- Valid Until : -
Date signed: ____________ Time signed: __________________
2012
Highest Nursing Degree Earned: ______________________
PNA No.:006559 Valid Until : December 31, 2009
Date signed: ____________ Time signed: __________________

For deliveries performed in Lying-In and Homes, ONLY THE

CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are
ODC Form 3
BAGUIO CENTRAL UNIVERSITY D.R. ASSIST
FORM
College of Nursing and School of Midwifery
ASSISTED DELIVERY in ________________________________________________________________________

Prepared by:
__________________________________________
Date Patient’s Name PROCEDURE D.R. SUPERVISED BY

Performed Case Number PERFORMED Nurse/Midwife Clinical Instructor
and (not applicable for On Duty Name and Signature
Time Started Birthing /Lying-In
Clinics/Homes) (Name only)


For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL

INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN
College of Nursing and School of Midwifery D.R. IMMEDIATE
NEWBORN
CORD CARE FORM
IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________
Prepared by:
_________________________________________
Date Patient’s Name Immediate Newborn Cord SUPERVISED BY

Performed Care PERFORMED Nurse/Midwife On Clinical Instructor
and Case Number Name and Signature
(not applicable for Indicate where performed e.g. Duty
Time Started Birthing Homes/Lying- D.R., Nursery, NICU, or Home (Name only)
InClinics/Homes)


For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL

INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN
GENERAL INSTRUCTIONS ON THE USE OF THESE FORMS:
Rule 1: Logic dictates that these forms should be applied only to the in-coming Nursing students in
Levels I and II only of Academic Year 2008-2009 onwards until their graduation and until
new issuances are released by the Board of Nursing;
Rule 2: All those filing applications for this November 2008 Nurse Licensure Examinations and the
succeeding NLEs “prior to the effectivity of these NEW FORMS” should all be accepted by
the Central and Regional PRC Offices without any condition. If there are any noted
discrepancies or any untoward observations, the Board of Nursing requires appropriate
documentation and reporting from the respective PRC Offices and should be received by
the Board of Nursing until after the last day of the NLE. Everything should be directed as
official communications to the Board of Nursing;
Rule 3: As a matter of policy, graduates ARE NOT TO BE PENALIZED for any discrepancies and
therefore all applications duly submitted “on time” MUST BE ACCEPTED. The Board of
Nursing shall take necessary actions based on official reports received by the same at the
Central Office within the prescribed period as set in Rule 2;
As a general rule the Board of Nursing subscribes to the principle of “loco parentis”. The college
and its administration directly involved in the care and supervision of students/graduates
are and shall be responsible and accountable to the lawful authorities.
BOARD OF NURSING

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BAGUIO CENTRAL UNIVERSITY ODC Form 1

O.R. SCRUB FORM

SURGICAL SCRUB in ________________________________________________________________________

Date Patient’s Name O.R. Nurse On SUPERVISED BY

Noted by: GINA L. CASI, RN Concurred by: ______________________________________

Approved by: FLORENCE C. CAWAON, Ed.D.

SURGICAL SCRUB in ________________________________________________________________________

Date Patient’s Name O.R. Nurse On SUPERVISED BY

Noted by: GINA L. CASI, RN Concurred by: ______________________________________

Approved by: FLORENCE C. CAWAON, Ed.D.

Name of Student ______________________________________________ Signature of Student _______

Date Patient’s Name PROCEDURE D.R. SUPERVISED BY

Concurred by: ______________________________________

Approved by: FLORENCE C. CAWAON, Ed.D.

For deliveries performed in Lying-In and Homes, ONLY THE

ASSISTED DELIVERY in ________________________________________________________________________

Date Patient’s Name PROCEDURE D.R. SUPERVISED BY

Noted by: GINA L. CASI, RN Concurred by: ______________________________________

Approved by: FLORENCE C. CAWAON, Ed.D.

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL

Date Patient’s Name Immediate Newborn Cord SUPERVISED BY

Noted by: GINA L. CASI, RN Concurred by: ______________________________________

Approved by: FLORENCE C. CAWAON, Ed.D.

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL

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Name of Student ________________________________________ Signature of Student _