FATHER SATURNINO URIOS UNIVERSITY

NURSING PROGRAM
BUTUAN CITY
San Francisco St. Butuan City 8600, Region XIII Caraga Philippines
Tel. Number 085-3413001 local 4852 and 4853
Accredited: PACUCOA Level II, PAASCU Level II

OPERATING ROOM SCRUB FORM

MAJOR

RONAH CELINE M. AQUINO_________

PRINTED NAME WITH SIGNATURE

DATE
PATIENT’S SUPERVISED BY
PERFORMED SURGICAL PROCEDURE NAME OF O.R. NURSE ON DUTY
INITIALS NAME AND SIGNATURE
AND TIME PERFORMED INSTITUTION (Name and Signature)
CASE NUMBER (CLINICAL INSTRUCTOR)
STARTED
March 21, 2022 10:30 Extracapsular Cataract Extraction with Manuel J. Santos
E. S. R 663407B
AM Intraocular Lens Implantation Hospital Rizalina B. Timogan, RN, MAN
Dechristian A. Tacmo, RN

March 24, 2022 2:02 PM L. L. S 663977B Removal of foreign body (slug), Left knee Manuel J. Santos Hospital
Ken Gerald Barbosa, RN Rizalina B. Timogan, RN, MAN

June 8, 2022 2:54 PM V.C..D 196977 Emergency Appendectomy Manuel J. Santos Hospital
Rhea Mih Tagalog, RN Rizalina B. Timogan, RN, MAN

Noted by : SHERYL MAE L. CIENCIA Approved by : TARCISIO B. CANDOG JR

Clinical Coordinator Dean, Nursing Program

PRC Number : 0394378 PRC Number : 0306591

Valid Until : May 15, 2024 Valid Until : July 23, 2024___
Date Signed : Date Signed :
Time : Time :
Highest Nursing Degree Earned: RN, MAN Highest Nursing Degree Earned: RN, MAN
 FATHER SATURNINO URIOS UNIVERSITY
NURSING PROGRAM
BUTUAN CITY
San Francisco St. Butuan City 8600, Region XIII Caraga Philippines
Tel. Number 085-3413001 local 4851 and 4852
Accredited: PACUCOA Level II, PAASCU Level II

OPERATING ROOM
CIRCULATING NURSE FUNCTION FORM

RONAH CELINE M. AQUINO…..…

PRINTED NAME WITH SIGNATURE

DATE
PATIENT’S SUPERVISED BY
PERFORMED SURGICAL PROCEDURE NAME OF O.R. NURSE ON DUTY
INITIALS CASE NAME AND SIGNATURE
AND TIME PERFORMED INSTITUTION (Name and Signature)
NUMBER (CLINICAL INSTRUCTOR)
STARTED
April 20, 2022 2:24 PM L.M.P 2022-04-00672 Total Abdominal Hysterectomy Butuan Medical Center Mary Lois Charity C. Elicano, RN,
Chrisnan Elvie Villones, RN MAN

Second repeat Lower Segment Transverse

April 21, 2022 11:20 AM C.A.R 2022-04-00760 Butuan Medical Center Mary Lois Charity C. Elicano, RN,
Cesarean Section + Bilateral Tubal Ligation
Chrisnan Elvie Villones, RN MAN

April 22, 2022 C.Z 2022-04-0684 Open Treatment (plate), Ulna right Butuan Medical Center Mary Lois Charity C. Elicano, RN,
Alger L. Peggy, RN MAN

Noted by : SHERYL MAE L. CIENCIA Approved by : TARCISIO B. CANDOG JR.

Clinical Coordinator Dean, Nursing Program

PRC Number : 0394378 PRC Number : 0306591

Valid Until : May 15, 2024 Valid Until : July 23, 2024___
Date Signed : Date Signed :
Time : Time :
Highest Nursing Degree Earned: RN, MAN Highest Nursing Degree Earned: RN, MAN
 FATHER SATURNINO URIOS UNIVERSITY
NURSING PROGRAM
BUTUAN CITY
San Francisco St. Butuan City 8600, Region XIII Caraga Philippines
Tel. Number 085-3413001 local 4851 and 4852
Accredited: PACUCOA Level II, PAASCU Level II

OPERATING ROOM/OUT PATIENT DEPARTMENT/EMERGENCY ROOM

ACQUIRED MINOR CASES FORM

…..…RONAH CELINE M. AQUINO________

PRINTED NAME WITH SIGNATURE
DATE
PATIENT’S SUPERVISED BY
PERFORMED SURGICAL PROCEDURE O.R. NURSE ON DUTY
INITIALS NAME OF INSTITUTION NAME AND SIGNATURE
AND TIME PERFORMED (Name and Signature)
CASE NUMBER (CLINICAL INSTRUCTOR)
STARTED
March 23, 2022 12: 45
M. V 663834B Excision Manuel J. Santos Hospital
PM Rizalina B. Timogan, RN, MAN
Niselle Ann N. Reboquio RN
Manuel J. Santos
March 24, 2022 4: 15 PM A.A 663725B Excision
Hospital Rizalina B. Timogan, RN, MAN
Danisa Shahani S. Dolotina, RN
Intraarticular Steroid Injection- Right Manuel J. Santos
June 8, 2022 4:43 PM E.U.E 677688B
shoulder Hospital Rizalina B. Timogan, RN, MAN
Vince R. Saligue, RN

Noted by : SHERYL MAE L. CIENCIA Approved by : TARCISIO B. CANDOG JR.

Clinical Coordinator Dean, Nursing Program

PRC Number : 0394378 PRC Number : 0306591

Valid Until : May 15, 2024 Valid Until : July 23, 2024___
Date Signed : Date Signed :
Time : Time :
Highest Nursing Degree Earned: RN, MAN Highest Nursing Degree Earned: RN, MAN
 FATHER SATURNINO URIOS UNIVERSITY
NURSING PROGRAM
BUTUAN CITY
San Francisco St. Butuan City 8600, Region XIII Caraga Philippines
Tel. Number 085-3413001 local 4851 and 4852
Accredited: PACUCOA Level II, PAASCU Level II
DELIVERY ROOM
ACTUAL/HANDLE FORM

RONAH CELINE M. AQUINO…..…

PRINTED NAME WITH SIGNATURE
DATE O.R. NURSE ON
PATIENT’S SUPERVISED BY
PERFORMED NAME OF DUTY
INITIALS CASE PROCEDURE PERFORMED NAME AND SIGNATURE
AND TIME INSTITUTION (Name and
NUMBER (CLINICAL INSTRUCTOR)
STARTED Signature)
November 12, 2019 1: NSVD with episiotomy and repair + cord coil Agusan del Norte Provincial
L.P.B 27-82-67
36 PM +1 G2P2 Hospital
Rowela C. Bequibel, R.N. Oliva L. Asendente, RN,MAN
November 18, 2019 Agusan del Norte Provincial
M.J.B.M 27-84-79 NSVD with repair of Laceration
11:10 AM Hospital
Rowela C. Bequibel, R.N. Oliva L. Asendente, RN,MAN
G2P2 (2022) Pregnancy Uterine 38 5/7
March 21, 2022 5: 24
S.J.N 215077 weeks, cephalic, delivered via NSVD in a live Manuel J. Santos Hospital
PM
term baby boy Niselle Ann N. Reboquio RN Rizalina B. Timogan, RN, MAN

Noted by : SHERYL MAE L. CIENCIA Approved by : TARCISIO B. CANDOG JR.

Clinical Coordinator Dean, Nursing Program

PRC Number : 0394378 PRC Number : 0306591

Valid Until : May 15, 2024 Valid Until : July 23, 2024___
Date Signed : Date Signed :
Time : Time :
Highest Nursing Degree Earned: RN, MAN Highest Nursing Degree Earned: RN, MAN
 FATHER SATURNINO URIOS UNIVERSITY
NURSING PROGRAM
BUTUAN CITY
San Francisco St. Butuan City 8600, Region XIII Caraga Philippines
Tel. Number 085-3413001 local 4851 and 4852
Accredited: PACUCOA Level II, PAASCU Level II
DELIVERY ROOM
ASSIST DELIVERY FORM

RONAH CELINE M. AQUINO______ …..…

PRINTED NAME WITH SIGNATURE
O.R. NURSE ON
DATE PATIENT’S SUPERVISED BY
NAME OF DUTY
PERFORMED AND INITIALS CASE PROCEDURE PERFORMED NAME AND SIGNATURE
INSTITUTION (Name and
TIME STARTED NUMBER (CLINICAL INSTRUCTOR)
Signature)
November 11, 2019 4: 14 Agusan del Norte Provincial
M.E.A 27-82-32 Breach Extraction G5P5
PM Hospital
Gian Carlo R. Suyo, RN Oliva L. Asendente, RN,MAN

November 18, 2019 2:22 Agusan del Norte Provincial

R.P.A 22-84-82 NSVD with Episiotomy and repair
PM Hospital
Rowela C. Bequibel, R.N. Oliva L. Asendente, RN,MAN
G4P1 (1021) Pregnancy uterine 38 2/7 weeks,
cephalic via NSVD to a live term baby girl; BW:
2.42 kg; A.S: 8,9; SGA: Antiphospholipid
March 23, 2022 11: 40 AM C.L.P 221338 Manuel J. Santos Hospital
antibody syndrome (APAS) with recurrent
Patricia Anne Jaramillo, RN Rizalina B. Timogan, RN, MAN
pregnancy loss: Gestational diabetes on insulin;
intrauterine growth restriction

Noted by : SHERYL MAE L. CIENCIA Approved by : TARCISIO B. CANDOG JR.

Clinical Coordinator Dean, Nursing Program

PRC Number : 0394378 PRC Number : 0306591

Valid Until : May 15, 2024 Valid Until : July 23, 2024___
Date Signed : Date Signed :
Time : Time :
Highest Nursing Degree Earned: RN, MAN Highest Nursing Degree Earned: RN, MAN
 FATHER SATURNINO URIOS UNIVERSITY
NURSING PROGRAM
BUTUAN CITY
San Francisco St. Butuan City 8600, Region XIII Caraga Philippines
Tel. Number 085-3413001 local 4851 and 4852
Accredited: PACUCOA Level II, PAASCU Level II

DELIVERY ROOM
IMMEDIATE CARE OF THE NEWBORN FORM

___RONAH CELINE M. AQUINO_…..…

PRINTED NAME WITH SIGNATURE
DATE PATIENT’S SUPERVISED BY
PROCEDURE O.R. NURSE ON DUTY
PERFORMED AND INITIALS NAME OF INSTITUTION NAME AND SIGNATURE
PERFORMED (Name and Signature)
TIME STARTED CASE NUMBER (CLINICAL INSTRUCTOR)
November 13, 2019 9: 15 Cesarean section + Bilateral Agusan del Norte Provincial
R.C.O 27-82-52
AM Tubal Ligation (transverse) Hospital
Rowela C. Bequibel, R.N. Rizalina B. Timogan, RN, MAN
November 20, 2019 9: 09 Normal Spontaneous Vaginal Agusan del Norte Provincial
L.A.D 27-85-29
AM Delivery With repair of laceration Hospital
Rowela C. Bequibel, R.N. Rizalina B. Timogan, RN, MAN
Normal Spontaneous Vaginal
March 22, 2022 7: 35 AM L.L.H 290000 Delivery (Pregnancy uterine 40 Manuel J. Santos Hospital
Lorraine Gonzaga, RN
weeks, cephalic) Rizalina B. Timogan, RN, MAN

Noted by : SHERYL MAE L. CIENCIA Approved by : TARCISIO B. CANDOG JR.

Clinical Coordinator Dean, Nursing Program

PRC Number : 0394378 PRC Number : 0306591

Valid Until : May 15, 2024 Valid Until : July 23, 2024___
Date Signed : Date Signed :
Time : Time :
Highest Nursing Degree Earned: RN, MAN Highest Nursing Degree Earned: RN, MAN