University of the Cordilleras

COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
==============================================
OPERATING ROOM SCRUB CASE SLIP:
Major ( ) Minor ( )

Agency: _________________________________________________________________________________
Hospital ( ) Community ( ) Medical Mission ( )
Address of Agency: ______________________________________________________________________
Case Number ___________________ Age _______ Gender ______________________________________
Final Diagnosis___________________________________________________________________________
Operation Performed _____________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Date of Operation ________________________________________________________________________
Time started ___________________________Time completed ___________________________________
Type of Anesthesia _______________________________________________________________________
Anesthesia started___________________________ended________________________________________
Surgeon _________________________________________________________________________________
Anesthesiologist__________________________________________________________________________
Instrument Nurse_________________________________________________________________________
Sponge Nurse ____________________________________________________________________________
Circulating Nurse ________________________________________________________________________
Name and Signature of OR Nurse__________________________________________________________

_____________________________________________
Clinical Instructor’s full Name and Signature
PRC Number _______________ Validity ____________________
PNA Number _______________ Regular ( ) Life Time ( )
CI: No erasures
Complete and correct data
Sign in blue pen
UC-VPAA-CON-FORM-10a
JUNE 2012 REV. 00

University of the Cordilleras

COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
==============================================
University of the Cordilleras
OPERATING ROOM CIRCULATING
COLLEGE OF NURSING CASE SLIP:
Major
Gov. Pack ( ) 2600
Road, Minor ( ) City
Baguio
==============================================
Agency: _________________________________________________________________________________
DELIVERY CASE SLIP: Actual ( ) Assist ( )
Hospital ( ) Community ( ) Medical Mission ( )
Address of Agency: _______________________________________________________________________
Agency: ________________________________________________________________________________
Hospital ( ) Home ( ) Birthing/ Lying-in ( )
Case Number
Address _____________________
of Agency: Age ________ Gender ___________________________________
______________________________________________________________________
Operation Performed _____________________________________________________________________
_____________________________________________________________________________________
Case_____________________________________________________________________________________
Number ___________________________ Age ____________________________________________
Date of Operation
Type ________________________________________________________________________
Delivery Attended ______________________________________________________________
Time____________________________________________________________________________________
started ____________________________ Time completed _________________________________
Scrub Nurse 1____________________________________________________________________________
____________________________________________________________________________________
Date ofNurse
Scrub 2____________________________________________________________________________
Delivery _________________________________________________________________________
Circulating Nurse ________________________________________________________________________
Time of Delivery _______________________ Time Placenta Out ________________________________
Name of OR Nurse ______________________________________________________________________
Actual Nurse ____________________________________________________________________________
Assist Nurse _____________________________________________________________________________
Name of DR Nurse/ Midwife _____________________________________________
_____________________________________________________________
Clinical Instructor’s full Name and Signature
PRC Number _______________ Validity ____________________
_____________________________________________
PNA Number _______________ Regularfull
Clinical Instructor’s ( ) Name
Life Time ( )
and Signature

CI: PRC Number _______________ Validity ____________________

No erasuresPNA Number _______________ Regular ( ) Life Time ( )
Complete and correct data
Sign in blue pen
CI:
No erasures
Complete and correct data
UC-VPAA-CON-FORM-10b_RLE
Sign
Marchin11,
blue
2015pen REV: 00

UC-VPAA-CON-FORM-10c_RLE
March 11, 2015 REV. 01
 University of the Cordilleras
COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
==============================================
IMMEDIATE NEWBORN CARE CASE SLIP
Agency: _________________________________________________________________________________
Hospital ( ) Home ( ) Birthing/ Lying-in ( )
Address: ________________________________________________________________________________

Date of Delivery________________________________ Time _____________________________________

Case Number ______________________________ Gender ______________________________________
Immediate Newborn Care Performed at:
Delivery Room ( )
Home ( )
Nursery ( )
Others ______________________________________________________________________
Name of Performing Nurse ______________________________________________________________
Name of DR/ Nursery Nurse /Midwife: ___________________________________________________

_____________________________________________
Clinical Instructor’s full Name and Signature

PRC Number _______________ Validity ____________________

PNA Number _______________ Regular ( ) Life Time ( )

CI:
No erasures
Complete and correct data
Sign in blue pen

UC-VPAA-CON-FORM-10d_RLE
March 11, 2015 REV. 01