ARELLANO UNIVERSITY ODC Form 2A

COLLEGE of NURSING O.R. SCRUB MAJOR FORM

2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Major) in ______________________________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ____________________________________________

Date Performed Patient’s INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical instructor
Time Started Case Number Name and Signature

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 2B
COLLEGE of NURSING O.R. SCRUB MINOR FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

SURGICAL SCRUB (Minor) in ______________________________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ____________________________________________

Date Performed Patient’s INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical instructor
Time Started Case Number Name and Signature

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 1A
COLLEGE of NURSING ACTUAL DELIVERY FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ACTUAL DELIVERY in______________________________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student ____________________________________________

Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty (Name and Signature) SUPERVISED BY
and PERFORMED (If Midwife on Duty, Signature Not Required) Clinical instructor
Time Started Case Number Name and Signature
(not applicable for Birthing/Lying-
in Clinic/Home)

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 1B
COLLEGE of NURSING ASSISTED DELIVERY FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

ASSISTED DELIVERY in ______________________________________________________________________

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

Prepared by:

Printed Name and Signature of Student ____________________________________________

Date Performed Patient’s INITIAL Only PROCEDURE D.R. Nurse On Duty (Name and Signature) SUPERVISED BY
and PERFORMED (If Midwife on Duty, Signature Not Required) Clinical instructor
Time Started Case Number Name and Signature
(not applicable for Birthing/Lying- ASSISTED DELIVERY
in Clinic/Home)

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN
 ARELLANO UNIVERSITY ODC Form 1C
COLLEGE of NURSING O.R. SCRUB MAJOR FORM
2600 Legarda St., Sampaloc, Manila
7347371 LOC 222/210, 7353509 Fax, www.arellano.edu.ph
PACUCOA Level II Re-Accredited Status (February 2010 to February 2015)

IMMEDIATE NEWBORN CORD CARE in ______________________________________________________________________

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

Prepared by:

Printed Name and Signature of Student ____________________________________________

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

Noted by: LEONARDO M. NUESTRO JR., RN, MAN Approved by: ROBERTO C. SOMBILLO, RN, RM, MAN
Clinical Coordinator, PRC I.D. No. 190198 Valid Until March 25, 2013 Dean, PRC I.D. No. 0172832 Valid Until August 02, 2013
Date document is signed: ________________ Time: ______________ Date document is signed: ________________ Time: _____________
Highest Nursing Degree Earned: BSN, MAN Highest Nursing Degree Earned: BSN, Midwifery, MAN