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    This document contains forms from Ateneo de Davao University for nursing students to record their surgical scrub and circulating nurse experiences in hospitals. The forms include spaces for the student's name and signature, date, patient's initials, surgical procedure performed, supervising OR nurse and clinical instructor's names and signatures. The forms must be noted and approved by the clinical coordinator and dean of the university nursing program.

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    This document contains forms from Ateneo de Davao University for nursing students to record their surgical scrub and circulating nurse experiences in hospitals. The forms include spaces for the student's name and signature, date, patient's initials, surgical procedure performed, supervising OR nurse and clinical instructor's names and signatures. The forms must be noted and approved by the clinical coordinator and dean of the university nursing program.

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    This document contains forms from Ateneo de Davao University for nursing students to record their surgical scrub and circulating nurse experiences in hospitals. The forms include spaces for the student's name and signature, date, patient's initials, surgical procedure performed, supervising OR nurse and clinical instructor's names and signatures. The forms must be noted and approved by the clinical coordinator and dean of the university nursing program.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
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    4 views3 pages

    Or Exhibit Form

    Uploaded by

    Aewooncardivilla21
    This document contains forms from Ateneo de Davao University for nursing students to record their surgical scrub and circulating nurse experiences in hospitals. The forms include spaces for the student's name and signature, date, patient's initials, surgical procedure performed, supervising OR nurse and clinical instructor's names and signatures. The forms must be noted and approved by the clinical coordinator and dean of the university nursing program.

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    of 3

    Ateneo de Davao University ODC Form 2A

    E. Jacinto St., Davao City O.R. SCRUB FORM


    (082) 221-2411 / www.addu.edu.ph Major
    Granted Autonomy by CHED, Year 2002

    SURGICAL SCRUB in _____________________________________________________________________________


    Hospital, Municipality/ City/ Province
    Prepared by:
    Printed Name with Signature of Student ___________________________________________________________

    Date Pa�ent’s INITIALS (only) SUPERVISED BY


    Performed SURGICAL PROCEDURE O.R Nurse on Duty Clinical Instructor
    and Case Number PERFORMED (Name AND Signature) Name and Signature
    Started

    Noted by: _______________________________________________________ Approved by: _________________________________________________


    (Print Name and Signature) (Print Name and Signature)
    Clinical Coordinator, PRC I.D No. ________________ Valid Un�l____________ Dean, PRC I.D. No. ______________________ Valid Un�l ______________
    Date document is signed: ______________________ Time________________ Date document is signed: _________________ Time__________________
    Please specify Highest Nursing Degree Earned:__________________________ Please specify Highest Nursing Degree Earned:______________________

    (STRICTLY NO DESIGNATES)
    Ateneo de Davao University ODC Form 2A
    E. Jacinto St., Davao City O.R. SCRUB FORM
    (082) 221-2411 / www.addu.edu.ph Minor
    Granted Autonomy by CHED, Year 2002

    SURGICAL SCRUB in _____________________________________________________________________________


    Hospital, Municipality/ City/ Province
    Prepared by:
    Printed Name with Signature of Student ___________________________________________________________

    Date Pa�ent’s INITIALS (only) SUPERVISED BY


    Performed SURGICAL PROCEDURE O.R Nurse on Duty Clinical Instructor
    and Case Number PERFORMED (Name AND Signature) Name and Signature
    Started

    Noted by: _______________________________________________________ Approved by: _________________________________________________


    (Print Name and Signature) (Print Name and Signature)
    Clinical Coordinator, PRC I.D No. ________________ Valid Un�l____________ Dean, PRC I.D. No. ______________________ Valid Un�l ______________
    Date document is signed: ______________________ Time________________ Date document is signed: _________________ Time__________________
    Please specify Highest Nursing Degree Earned:__________________________ Please specify Highest Nursing Degree Earned:______________________

    (STRICTLY NO DESIGNATES)
    Ateneo de Davao University ODC Form 2B
    E. Jacinto St., Davao City CIRCULATING NURSE
    (082) 221-2411 / www.addu.edu.ph
    Granted Autonomy by CHED, Year 2002

    CIRCULATING NURSE in _____________________________________________________________________________


    Hospital, Municipality/ City/ Province
    Prepared by:
    Printed Name with Signature of Student ___________________________________________________________

    Date Pa�ent’s INITIALS (only) SUPERVISED BY


    Performed SURGICAL PROCEDURE O.R Nurse on Duty Clinical Instructor
    and Case Number PERFORMED (Name AND Signature) Name and Signature
    Started

    Noted by: _______________________________________________________ Approved by: _________________________________________________


    (Print Name and Signature) (Print Name and Signature)
    Clinical Coordinator, PRC I.D No. ________________ Valid Un�l____________ Dean, PRC I.D. No. ______________________ Valid Un�l ______________
    Date document is signed: ______________________ Time________________ Date document is signed: _________________ Time__________________
    Please specify Highest Nursing Degree Earned:__________________________ Please specify Highest Nursing Degree Earned:______________________

    (STRICTLY NO DESIGNATES)

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