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    New Forms of Cases PRC 2

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    Corenne Hope Obado
    This document contains forms for medical students to log their surgical scrubs, actual deliveries, and assisted deliveries in various hospitals and clinics. The forms require the student's name and signature, dates and times of procedures, patient initials, case numbers if applicable, procedures performed, supervising nurses or midwives, and signatures from the clinical coordinator and dean to verify the records.

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    New Forms of Cases PRC 2

    Uploaded by

    Corenne Hope Obado
    10 views6 pages
    This document contains forms for medical students to log their surgical scrubs, actual deliveries, and assisted deliveries in various hospitals and clinics. The forms require the student's name and signature, dates and times of procedures, patient initials, case numbers if applicable, procedures performed, supervising nurses or midwives, and signatures from the clinical coordinator and dean to verify the records.

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    This document contains forms for medical students to log their surgical scrubs, actual deliveries, and assisted deliveries in various hospitals and clinics. The forms require the student's name and signature, dates and times of procedures, patient initials, case numbers if applicable, procedures performed, supervising nurses or midwives, and signatures from the clinical coordinator and dean to verify the records.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    10 views6 pages

    New Forms of Cases PRC 2

    Uploaded by

    Corenne Hope Obado
    This document contains forms for medical students to log their surgical scrubs, actual deliveries, and assisted deliveries in various hospitals and clinics. The forms require the student's name and signature, dates and times of procedures, patient initials, case numbers if applicable, procedures performed, supervising nurses or midwives, and signatures from the clinical coordinator and dean to verify the records.

    Copyright:

    © All Rights Reserved
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    of 6

    SCHOOL OF MEDICAL SCIENCES

    OR Circulating Form
    Accredited Level II –ACSCU-AAI: May 2023 - May 2026

    Surgical Scrub in ________________________________________________


    Hospital, Municipality/City/Province

    Prepared by:
    Name of Student: __________________________________ Signature of Student: _________________________________________

    Date Performed Patient’s Initial Only SUPERVISEDBY


    And Procedure Performed OR Nurse on Duty (Name Only) Clinical Instructor
    Time Started Case Number Name and Signature

    Noted by: Concurred by:

    LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


    Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
    Date Signed: _________________ Date Signed: __________________
    Time Signed:_________________ Time Signed: _________________
    Degree: RN, MAN_______________ Degree: RN, MSN_______________
    a. PRC No. 0279667____________ a. PRC No. 0270024____________
    Valid until: October 12, 2023_ Valid until: November 17, 2025
    b. PNA No. _____________ b. PNA No. _______________
    Valid until: ____________ Valid until: _____________
    c. ADPCN No. 11-304
    Valid until: _________
    SCHOOL OF MEDICAL SCIENCES
    Actual Form
    Accredited Level II –ACSCU-AAI: May 2023 - May 2026

    Actual Deliveries in ________________________________________________


    Hospital, Municipality/City/Province

    Prepared by:
    Name of Student: __________________________________ Signature of Student: ______________________________________ _________

    Patient’s Initial Only


    Date Performed D.R. Nurse/Midwife SUPERVISED BY
    And Case Number Procedure Performed On Duty Clinical Instructor
    Time Started (not applicable for Birthing/Lying- (Name only) Name and Signature
    In Clinics/Homes)

    Noted by: Concurred by:

    LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


    Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
    Date Signed: _________________ Date Signed: __________________
    Time Signed:_________________ Time Signed: _________________
    Degree: RN, MAN_______________ Degree: RN, MSN_______________
    b. PRC No. 0279667____________ a. PRC No. 0270024____________
    Valid until: October 12, 2023_ Valid until: November 17, 2025
    c. PNA No. _____________ b. PNA No. _______________
    Valid until: ____________ Valid until: _____________
    c. ADPCN No. 11-304
    Valid until: _________

    SCHOOL OF MEDICAL SCIENCES Assist


    Form
    Accredited Level II –ACSCU-AAI: May 2023 - May 2026

    ASSISTED DELIVERY in _________________________________________________


    Hospital/Home/Lying-In Clinic, Municipality/City/Province

    Prepared by:
    Name of Student: __________________________________ Signature of Student: _________________________________________

    Patient’s Initial Only


    Date Performed D.R. Nurse/Midwife SUPERVISED BY
    And Case Number Procedure Performed On Duty Clinical Instructor
    Time Started (not applicable for Birthing/Lying- (Name only) Name and Signature
    In Clinics/Homes)

    Noted by: Concurred by:

    LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


    Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
    Date Signed: _________________ Date Signed: __________________
    Time Signed:_________________ Time Signed: _________________
    Degree: RN, MAN_______________ Degree: RN, MSN_______________
    c. PRC No. 0279667____________ a. PRC No. 0270024____________
    Valid until: October 12, 2023_ Valid until: November 17, 2025
    d. PNA No. _____________ b. PNA No. _______________
    Valid until: ____________ Valid until: _____________
    c. ADPCN No. 11-304
    Valid until: _________
    SCHOOL OF MEDICAL SCIENCES
    Cord Care Form
    Accredited Level II –ACSCU-AAI: May 2023 - MAy 2026

    IMMEDIATE NEWBORN CORD CARE in ___________________________________________________


    Hospital/Home/Lying-In Clinic, Municipality/City/Province

    Prepared by:
    Name of Student: __________________________________ Signature of Student: _________________________________________

    Patient’s Initial Only Immediate Newborn Cord Care


    Date Performed PERFORMED D.R. Nurse/Midwife SUPERVISED BY
    And Case Number Indicate where performed e.g. D.R., On Duty Clinical Instructor
    Time Started (not applicable for Birthing/Lying- Nursery, (Name only) Name and Signature
    In Clinics/Homes) NICU, or Home

    Noted by: Concurred by:

    LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


    Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
    Date Signed: _________________ Date Signed: __________________
    Time Signed:_________________ Time Signed: _________________
    Degree: RN, MAN_______________ Degree: RN, MSN_______________
    d. PRC No. 0279667____________ a. PRC No. 0270024____________
    Valid until: October 12, 2023_ Valid until: November 17, 2025
    e. PNA No. _____________ b. PNA No. _______________
    Valid until: ____________ Valid until: _____________
    c. ADPCN No. 11-304
    Valid until: _________

    SCHOOL OF MEDICAL SCIENCES


    OR Scrub Form
    Accredited Level II –ACSCU-AAI: May 2023 - May 2026

    Surgical Scrub in ________________________________________________


    Hospital, Municipality/City/Province

    Prepared by:
    Name of Student: __________________________________ Signature of Student: _________________________________________

    Date Performed Patient’s Initial Only SUPERVISEDBY


    And Procedure Performed OR Nurse on Duty (Name Only) Clinical Instructor
    Time Started Case Number Name and Signature

    Noted by: Concurred by:

    LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


    Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
    Date Signed: _________________ Date Signed: __________________
    Time Signed:_________________ Time Signed: _________________
    Degree: RN, MAN_______________ Degree: RN, MSN_______________
    e. PRC No. 0279667____________ a. PRC No. 0270024____________
    Valid until: October 12, 2023_ Valid until: November 17, 2025
    f. PNA No. _____________ b. PNA No. _______________
    Valid until: ____________ Valid until: _____________
    c. ADPCN No. 11-304
    Valid until: _________

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