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  • Name and Address of Patient Case No. Date & Time Performed Supervised By: License & Exp. Date Signature

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    Mechaila Babor
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    This document appears to be a record form for documenting internal examinations, procedures, and deliveries conducted by midwifery students and trainees. It includes fields for patient name and details, case number, diagnosis, date and time of the conduct procedure, supervising midwife's name and license information, and spaces for signatures. The procedures that can be documented include internal examinations, intravenous fluid insertions, suturing of perineal lacerations, and records of normal deliveries. The document indicates it is from the Professional Regulation Commission and Board of Midwifery in the Philippines.

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    This document appears to be a record form for documenting internal examinations, procedures, and deliveries conducted by midwifery students and trainees. It includes fields for patient name and details, case number, diagnosis, date and time of the conduct procedure, supervising midwife's name and license information, and spaces for signatures. The procedures that can be documented include internal examinations, intravenous fluid insertions, suturing of perineal lacerations, and records of normal deliveries. The document indicates it is from the Professional Regulation Commission and Board of Midwifery in the Philippines.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    11 views18 pages

    Name and Address of Patient Case No. Date & Time Performed Supervised By: License & Exp. Date Signature

    Uploaded by

    Mechaila Babor
    This document appears to be a record form for documenting internal examinations, procedures, and deliveries conducted by midwifery students and trainees. It includes fields for patient name and details, case number, diagnosis, date and time of the conduct procedure, supervising midwife's name and license information, and spaces for signatures. The procedures that can be documented include internal examinations, intravenous fluid insertions, suturing of perineal lacerations, and records of normal deliveries. The document indicates it is from the Professional Regulation Commission and Board of Midwifery in the Philippines.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as xlsx, pdf, or txt
    of 18

    Internal Examination (Cervical Dilation, SUPERVISED BY:

    Name and Address of Patient Case No. Effacement, BOW, Presentation & Station) Date & Time Performed Full Name & Address of Facility &
    Contact Number License & Exp. Date
    Printed Name & Contact Number Position/Designation Signature

    Note: 1) The Clinical Instructor should ensure the competence of the students in the performance of internal examinations before signing this form.
    2) Registered Midwives/Clinical Instructors who supervise Students/Graduate Midwives/Registered Nurses and affix their signature in this Form must present a
    Certificate of Training on the Expanded Functions of Midwife (R.A. 7392) pursuant to Board Resolution No. 07, Series of 2017, dated September 8, 2017.

    SUBSCRIBED AND WORN To before me this CERTIFIED CORRECT:


    ___________________ at _________________ Affiant
    exhibiting to me her Resident Certificate No. 14231162 Printed Name & Signature: JUVY C. HINOSO, RN, RM, MN
    issued at Kabankalan City, Negros Occidental on June 7, 2022 Affix doc. Date Signed:
    stamp Designation : Principal
    License No.: 0150130 Valid Until: October 11, 2024
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF CONDUCTED INTERNAL EXAMINATION BEFORE DELIVERY


    Please Check:
    Graduate Midwife Registered Nurse

    Name of Applicant: School: FELLOWSHIP BAPTIST COLLEGE


    Internal Examination (Cervical Dilation, SUPERVISED BY:
    Name and Address of Patient Case No. Effacement, BOW, Presentation & Station) Date & Time Performed Full Name & Address of Facility &
    Contact Number License & Exp. Date
    Printed Name & Contact Number Position/Designation Signature

    .
    .
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF ACTUAL INTRAVENOUS FLUID INSERTION

    Please Check:
    Graduate Midwife Registered Nurse

    Name of Applicant: School: FELLOWSHIP BAPTIST COLLEGE


    Date & Time Full Name & Address of Facility & Check if SUPERVISED BY: License &
    Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_)
    Performed Contact Number Exp. Date
    Home Del. Printed Name & Contact Number Position/Designation Signature

    .
    G1P1 (1-0-0-1) PUFT 40 wks AOG, Alderman's Natal Clinic, Rizal
    Cephalic in Labor, Delivered NSVD to Ext. Brgy.9, Kabankalan City
    an alive Bb Girl APGAR=9 BW 3,000 ANALYN M. PIOQUINTO,
    5213 grams, 1st degree Vaginal laceration
    suture done. January 23, 2020, 10:36 RM Clinical Instructor
    AM, IVF
    Cephalic in Labor, Delivered NSVD to
    an alive Bb Girl APGAR=9 BW 3,000
    grams, 1st degree Vaginal laceration
    suture done. January 23, 2020, 10:36
    AM, IVF
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF ACTUAL SUTURING OF PERINEAL LACERATIONS

    Please Check:
    Graduate Midwife Registered Nurse

    Name of Applicant: School: FELLOWSHIP BAPTIST COLLEGE


    Date & Time Full Name & Address of Facility & Check if SUPERVISED BY: License &
    Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_)
    Performed Contact Number Exp. Date
    Home Del. Printed Name & Contact Number Position/Designation Signature

    .
    PROFESSIONAL REGULATION COMMISSION
    Manila
    BOARD OF MIDWIFERY
    RECORD OF NORMAL DELIVERIES HANDLED
    Please Check:
    Graduate Midwife Registered Nurse

    Name of Applicant: School: FELLOWSHIP BAPTIST COLLEGE


    Full Name & Address of Check if SUPERVISED BY: License &
    Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performed Facility & Contact Number Exp. Date
    Home Del. Printed Name & Contact Number Position/Designation Signature
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF NORMAL DELIVERIES HANDLED

    Please Check:
    Graduate Midwife Registered Nurse

    Name of Applicant: School: FELLOWSHIP BAPTIST COLLEGE


    Full Name & Address of Check if SUPERVISED BY: License &
    Name and Address of Patient Case No. Complete Diagnosis (Gravida_Para_) Date & Time Performed Facility & Contact Number
    Home Del. Printed Name & Contact Number Position/Designation Signature Exp. Date

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