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 ( )

UC-VPAA-CON-FORM-10a
August 2018 REV. 01

University of the Cordilleras

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

Agency: _________________________________________________________________________________
Hospital ( ) Community ( ) Medical Mission ( )
Address of agency
_____________________________________________________________________________
Case Number ___________________ Age ______ Gender ___________________________________
Operation Performed __________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Date of Operation _____________________________________________________________________
Time started _____________ Time completed ____________________________________________
Scrub Nurse 1________________________________________________________________________
Scrub Nurse 2________________________________________________________________________
Circulating Nurse _____________________________________________________________________
Name of OR Nurse _____________________________________________________________________

_____________________________________________
Clinical Instructor’s full Name and signature

PRC Number _______________ Validity ____________________

PNA Number _______________ Regular ( ) Life Time ( )

UC-VPAA-CON-FORM-10b_RLE
August 2018 REV:01
 University of the Cordilleras
COLLEGE OF NURSING
Gov. Pack Road, 2600 Baguio City
==============================================
DELIVERY CASE SLIP: Actual ( ) Assist ( )

Agency: _________________________________________________________________________________
Hospital ( ) Home ( ) Birthing/ Lying-in ( )
Address of Agency:
____________________________________________________________________________
Case Number ___________________ Age __________________________________________________
Type of Delivery Attended _____________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Date of Delivery _________________________________________________________________________
Time of Delivery _____________ Time Placenta Out __________________________________________
Actual Nurse ___________________________________________________________________________
Assist Nurse ___________________________________________________________________________
Name of DR Nurse/ Midwife ___________________________________________________________

_________________________________
Clinical Instructor’s full Name and signature

PRC Number _______________ Validity ____________________

PNA Number _______________ Regular ( ) Life Time ( )

UC-VPAA-CON-FORM-10c_RLE
August 2018 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 of Agency:
____________________________________________________________________________

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 ( )

UC-VPAA-CON-FORM-10d_RLE
August 2018 REV. 01