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  • Procedure Performed Actual Delivery

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    Bembem Montenegro
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    This document contains forms from Batangas State University College of Nursing and Allied Health Sciences regarding clinical procedures performed by students. The forms include: 1) Actual delivery and assisted delivery forms to be completed for procedures performed at Batangas Medical Center under the supervision of clinical instructors. 2) A newborn cord care form to document immediate newborn cord care procedures. 3) Operating room scrub forms for major and minor surgical procedures performed under the supervision of OR nurses and clinical instructors. The forms require documentation of date, time, patient information, procedure performed, supervising staff and instructor signatures.

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    This document contains forms from Batangas State University College of Nursing and Allied Health Sciences regarding clinical procedures performed by students. The forms include: 1) Actual delivery and assisted delivery forms to be completed for procedures performed at Batangas Medical Center under the supervision of clinical instructors. 2) A newborn cord care form to document immediate newborn cord care procedures. 3) Operating room scrub forms for major and minor surgical procedures performed under the supervision of OR nurses and clinical instructors. The forms require documentation of date, time, patient information, procedure performed, supervising staff and instructor signatures.

    Copyright:

    © All Rights Reserved
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    15 views5 pages

    Procedure Performed Actual Delivery

    Uploaded by

    Bembem Montenegro
    This document contains forms from Batangas State University College of Nursing and Allied Health Sciences regarding clinical procedures performed by students. The forms include: 1) Actual delivery and assisted delivery forms to be completed for procedures performed at Batangas Medical Center under the supervision of clinical instructors. 2) A newborn cord care form to document immediate newborn cord care procedures. 3) Operating room scrub forms for major and minor surgical procedures performed under the supervision of OR nurses and clinical instructors. The forms require documentation of date, time, patient information, procedure performed, supervising staff and instructor signatures.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    of 5

    ODC Form 1A

    ACTUAL DELIVERY FORM


    BATANGAS STATE UNIVERSITY
    COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
    Pablo Borbon Main I, Rizal Avenue, Batangas City, Batangas, Philippines
    Tel No. (043) 300-2202 loc.120, (043) 300-2273 Email: batstateuconahs@yahoo.com
    AACUP ACCREDITED AS LEVEL I, December 2016

    ACTUAL DELIVERY in BATANGAS MEDICAL CENTER, Batangas City, Batangas

    Prepared by:
    Printed Name and Signature of Student ___________________________________________________________

    Date Performed Patient’s INITIAL Only PROCEDURE DR Nurse On Duty SUPERVISED BY


    PERFORMED (Name and Signature) Clinical Instructor
    and Case Number
    If Midwife on Duty, Name & Signature)
    Time Started Signature Not Required)
    ACTUAL DELIVERY

    Noted by: Asst Prof. Victoria M. Magpantay Approved by: Asst Prof. Charmaine Rose I. Triviño
    Clinical Coordinator, PRC I. D. No. ____________ Valid Until ____________ Dean, PRC I.D. No. __________________________ Valid Until _____________
    Date document is signed:______________________ Time ______________ Date document is signed ________________________ Time ______________
    Please specify Highest Nursing Degree Earned ________________________ Please specify Highest Nursing Degree Earned __________________________
    ODC Form 1B
    ASSISTED DELIVERY
    BATANGAS STATE UNIVERSITY FORM
    COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
    Pablo Borbon Main I, Rizal Avenue, Batangas City, Batangas, Philippines
    Tel No. (043) 300-2202 loc.120, (043) 300-2273 Email: batstateuconahs@yahoo.com
    AACUP ACCREDITED AS LEVEL I, December 2016

    ASSISTED DELIVERY in BATANGAS MEDICAL CENTER, Batangas City, Batangas

    Prepared by:
    Printed Name and Signature of Student ___________________________________________________________

    Date Performed Patient’s INITIAL Only PROCEDURE DR Nurse On Duty SUPERVISED BY


    PERFORMED (Name and Signature) Clinical Instructor
    and Case Number
    If Midwife on Duty, Name & Signature)
    Time Started ASSISTED DELIVERY Signature Not Required)

    Noted by: Asst Prof. Victoria M. Magpantay Approved by: Asst Prof. Charmaine Rose I. Triviño
    Clinical Coordinator, PRC I. D. No. ____________ Valid Until ____________ Dean, PRC I.D. No. __________________________ Valid Until _____________
    Date document is signed:______________________ Time ______________ Date document is signed ________________________ Time ______________
    Please specify Highest Nursing Degree Earned ________________________ Please specify Highest Nursing Degree Earned _________________________
    BATANGAS STATE UNIVERSITY
    COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES ODC Form 1C
    Pablo Borbon Main I, Rizal Avenue, Batangas City, Batangas, Philippines CORD CARE FORM
    Tel No. (043) 300-2202 loc.120, (043) 300-2273 Email: batstateuconahs@yahoo.com
    AACUP ACCREDITED AS LEVEL I, December 2016

    IMMEDIATE NEWBORN CORD CARE in BATANGAS MEDICAL CENTER, Batangas City, Batangas

    Prepared by:
    Printed Name and Signature of Student ___________________________________________________________

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

    Noted by: Asst Prof. Victoria M. Magpantay Approved by: Asst Prof. Charmaine Rose I. Triviño
    Clinical Coordinator, PRC I. D. No. ____________ Valid Until ____________ Dean, PRC I.D. No. __________________________ Valid Until _____________
    Date document is signed:______________________ Time ______________ Date document is signed ________________________ Time ______________
    Please specify Highest Nursing Degree Earned ________________________ Please specify Highest Nursing Degree Earned __________________________
    BATANGAS STATE UNIVERSITY
    COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES ODC Form 2A
    Pablo Borbon Main I, Rizal Avenue, Batangas City, Batangas, Philippines O.R. SCRUB FORM
    Tel No. (043) 300-2202 loc.120, (043) 300-2273 Email: batstateuconahs@yahoo.com
    AACUP ACCREDITED AS LEVEL I, December 2016 Major

    SURGICAL SCRUB in BATANGAS MEDICAL CENTER, Batangas City, Batangas

    Prepared by:
    Printed Name and Signature of Student ___________________________________________________________

    Date Performed Patient’s INITIAL Only O.R. Nurse On Duty SUPERVISED BY


    SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
    and Case Number
    PERFORMED Name & Signature)
    Time Started

    Noted by: Asst Prof. Victoria M. Magpantay Approved by: Asst Prof. Charmaine Rose I. Triviño
    Clinical Coordinator, PRC I. D. No. ____________ Valid Until ____________ Dean, PRC I.D. No. __________________________ Valid Until _____________
    Date document is signed:______________________ Time ______________ Date document is signed ________________________ Time ______________
    Please specify Highest Nursing Degree Earned ________________________ Please specify Highest Nursing Degree Earned __________________________
    BATANGAS STATE UNIVERSITY
    COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES ODC Form 2B
    Pablo Borbon Main I, Rizal Avenue, Batangas City, Batangas, Philippines O.R. MINOR FORM
    Tel No. (043) 300-2202 loc.120, (043) 300-2273 Email: batstateuconahs@yahoo.com
    AACUP ACCREDITED AS LEVEL I, December 2016

    SURGICAL SCRUB in BATANGAS MEDICAL CENTER, Batangas City, Batangas

    Prepared by:
    Printed Name and Signature of Student ___________________________________________________________

    Date Performed Patient’s INITIAL Only O.R. Nurse On Duty SUPERVISED BY


    SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
    and Case Number
    Name & Signature)
    PERFORMED
    Time Started

    Noted by: Asst Prof. Victoria M. Magpantay Approved by: Asst Prof. Charmaine Rose I. Triviño
    Clinical Coordinator, PRC I. D. No. ____________ Valid Until ____________ Dean, PRC I.D. No. __________________________ Valid Until _____________
    Date document is signed:______________________ Time ______________ Date document is signed ________________________ Time ______________
    Please specify Highest Nursing Degree Earned ________________________ Please specify Highest Nursing Degree Earned __________________________

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