Arcega R 1

GOLDEN GATE COLLEGES
P. Prieto St., Batangas City

Tel Nos. 723-2663/723-2471/723-7712/300-7642/Fax # (043) 723-2077/ggc_batangas_city@yahoo.com, www.goldengatecolleges.com
SURGICAL SCRUB in GOLDEN GATE GENERAL HOSPITAL

Hospital/Home/Lying-in Clinic, Municipality/City /Province
O.R. Form 1A
O.R. SCRUB
FORM
Prepared by:
Printed Name and Signature of Student: ROMAR RICO H. ARCEGA
Date Performed Patient’s INITIAL Only

and SURGICAL PROCEDURE O.R Nurse on Duty SUPERVISED BY
Time Started Case Number PERFORMED (Name & Signature) Clinical Instructor
Name and Signature
May 23, 2022 E.A.C. Extracapsular Cataract Extraction with
11:15 AM 0374 Intraoccular Lens in Left Eye Evelyn C. Cruzat ,RN Lyka D. Chavez, RN. MAN
May 24, 2022 J.M.B.S.
12:40 PM 0382 Thoracostomy with Drainage Analisa V. Bagon ,RN Lyka D. Chavez, RN. MAN
May 26, 2022 S.M.M.
01:05 PM 0397 Open Cholecystectomy Evelyn Cruzat ,RN Lyka D. Chavez, RN. MAN
SEMIRA ANN A. PANGANIBAN ,RN.MAN, PhD MARY JANE B. EBORA ,RN.MAN ALLAN O. DIMAANO ,RN.RM,MAN, PhD
Clinical Coordinator Chief Nurse Clinical Coordinator
Degree: BSPT, BSN MAN Degree: BSN MAN Degree: BSN, MAN, Ed.D
PRC No.: 0375643 PRC No.: 0370859 PRC No.: 0371413
Valid Until: November 7, 2024 Valid Until: September 19, 2024 Valid Until: February 03, 2024
PNA No.: M-37693 PNA No.: M-38546 PNA No.: M-37679
GOLDEN GATE
COLLEGES

O.R. Form 1B
O.R.
CIRCULAT
Prepared by:

Name and Signature
May 23, 2022 Z.B.C.
08:01 AM 0378 Appendectomy Evelyn C. Cruzat ,RN Lyka D. Chavez, RN. MAN
June 02, 2022 A.R.
10:05 AM 0449 Debridement, Burns Emilyn G. Milan ,RN Lyka D. Chavez, RN. MAN
June 03, 2022 R.D.L.
01:15 PM 0453 Excision, Breast mass Left Evelyn C. Cruzat ,RN Lyka D. Chavez, RN. MAN
SEMIRA ANN A. ,RN.MAN, MARY JANE B. ,RN.M ALLAN O. DIMAANO ,RN.RM,MAN,

PANGANIBAN EBORA PhD
Degree: BSPT, BSN MAN Degree: BSN, MAN Degree: BSN , MAN, Ed.D
PRC No.: 0375643 Valid Until: September 19, 2024 PRC No.: 0371413
Valid Until: November 7, 2024 PNA No.: M- 38546 Valid Until: February 03, 2024 PNA No.:
PNA No.: M-37693 37679
GOLDEN GATE
COLLEGES
IMMEDIATE NEWBORN CORD CARE in GOLDEN GATE GENERAL HOSPITAL

ICNB Form
IMMEDIATE CARE OF
THE
Prepared by:
Date Performed Patient’s INITIAL Only Immediate Newborn Cord Care Nurse on Duty SUPERVISED BY
and PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number Indicate where performed e.g. (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying- D.R., Nursery, NICU or Home Signature Not Required)
in Clinics/Homes)
March 24, 2019 B.D.C.
07:06 AM 2019-936 Cord Dressing Criza Katherine Pagsinohin, RN Lyka D. Chavez, RN. MAN
March 24, 2019 R.G.
10:15 AM 2019-937 Cord Dressing Criza Katherine Pagsinohin, RN Lyka D. Chavez, RN. MAN
March 24, 2019 A.T.
01:45 PM 2019-938 Cord Dressing Criza Katherine Pagsinohin, RN Lyka D. Chavez, RN. MAN

Degree: BSPT, BSN MAN Degree: BSN, MAN Degree: BSN , MAN, Ed.D
Valid Until: November 7, 2024 PNA No.: M- 38546 Valid Until: February 03, 2024 PNA No.:
PNA No.: M-37693 37679
GOLDEN GATE
COLLEGES
ACTUAL DELIVERY in GOLDEN GATE GENERAL HOSPITAL

D.R. FORM
ACTUAL DELIVERY
Prepared by:
Printed Name and Signature of Student : ROMAR RICO H. ARCEGA
Date Performed Patient’s INITIAL Only D. R. Nurse on Duty SUPERVISED BY

and (Name and Signature) Clinical Instructor
Time Started Case Number PROCEDURE PERFORMED (If Midwife on Duty, Name and Signature
(not applicable for Birthing/Lying- Signature Not Required)
in Clinics/Homes)
December 24, 2019 G.S.A.
06:31 AM 004 Normal Spontaneous Delivery Analisa V. Bagon ,RN Lyka D. Chavez, RN. MAN
December 24, 2019 J.M.J.
09:58 AM 005 Normal Spontaneous Delivery Evelyn C. Cruzat ,RN Lyka D. Chavez, RN. MAN.
December 24, 2019 K.C.R.
01:30 PM 006 Normal Spontaneous Delivery Analisa V. Bagon ,RN Lyka D. Chavez, RN. MAN

Degree: BSPT, BSN MAN Degree: BSN MAN Degree:BSN, MAN, Ed.D
Valid Until: November 7, 2024 PNA No.: M- 38546 Valid Until: February 03, 2024
PNA No.: M-37693 PNA No.: M-37679
GOLDEN GATE
COLLEGES

O.R. Form 1A
O.R. SCRUB
FORM
Prepared by:

Name and Signature
May 30, 2022 P.C.P.
08:15 AM 0436 Colonoscopy Evelyn Cruzat ,RN Lyka D. Chavez, RN. MAN
May 30, 2022 I.C.
09:10 AM 0440 Excision, Breast mass Right Analisa V. Bagon ,RN Lyka D. Chavez, RN. MAN
May 31, 2022 R.C.M.
10:05 AM 0445 Excision Evelyn Cruzat ,RN Lyka D. Chavez, RN. MAN
SEMIRA ANN A. ,RN.MAN, MARY JANE B. EBORA ALLAN O. DIMAANO ,RN.RM,MAN,

PANGANIBAN ,RN.MAN PhD
Degree: BSPT, BSN MAN Degree: BSN MAN Degree:BSN, MAN, Ed.D
PRC No.: 0375643 PRC No.: 0370859 PRC No.: 0371413
Valid Until: November 7, 2024 Valid Until: September 19, 2024 Valid Until: February 03, 2024
PNA No.: M-37693 PNA No.: M- 38546 PNA No.: M-37679

Arcega R 1

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GOLDEN GATE COLLEGES

P. Prieto St., Batangas City

SURGICAL SCRUB in GOLDEN GATE GENERAL HOSPITAL

Printed Name and Signature of Student: ROMAR RICO H. ARCEGA

Date Performed Patient’s INITIAL Only

SURGICAL SCRUB in GOLDEN GATE GENERAL HOSPITAL

Printed Name and Signature of Student: ROMAR RICO H. ARCEGA

Date Performed Patient’s INITIAL Only

SEMIRA ANN A. ,RN.MAN, MARY JANE B. ,RN.M ALLAN O. DIMAANO ,RN.RM,MAN,

IMMEDIATE NEWBORN CORD CARE in GOLDEN GATE GENERAL HOSPITAL

Printed Name and Signature of Student: ROMAR RICO H. ARCEGA

SEMIRA ANN A. ,RN.MAN, MARY JANE B. ,RN.M ALLAN O. DIMAANO ,RN.RM,MAN,

ACTUAL DELIVERY in GOLDEN GATE GENERAL HOSPITAL

Printed Name and Signature of Student : ROMAR RICO H. ARCEGA

Date Performed Patient’s INITIAL Only D. R. Nurse on Duty SUPERVISED BY

SEMIRA ANN A. ,RN.MAN, MARY JANE B. ,RN.M ALLAN O. DIMAANO ,RN.RM,MAN,

SURGICAL SCRUB in GOLDEN GATE GENERAL HOSPITAL

Printed Name and Signature of Student: ROMAR RICO H. ARCEGA

Date Performed Patient’s INITIAL Only

SEMIRA ANN A. ,RN.MAN, MARY JANE B. EBORA ALLAN O. DIMAANO ,RN.RM,MAN,

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