FAR EASTERN UNIVERSITY

Nicanor Reyes Sr. Street Sampaloc Manila 1008

Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
PAASCU, Level II Re-Accredited, May 2011
MAJOR SURGICAL SCRUB in _________________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _________________________________________
Date Performed
and
Time Started

Patients INITIALS (only)

SURGICAL PROCEDURE
PERFORMED

Case Number

O.R. Nurse on Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Noted by:

Concurred by:

Approved by:

MONICA C. LAGONOY - AONUEVO, RN, MAN__

Signature over printed name of Clinical Coordinator
Date signed:
____________________________
Degree:
Master of Arts in Nursing
__
PRC Lic. No. : 0158815
__
Valid Until:
May 4, 2013__________________
PNA No. :
2011-041254_________________
Valid Until:
December 2012_______________

___________________________________________
Signature over printed name of Chief Nurse
Date signed: _______________________________
Degree:
_______________________________
PRC Lic. No.: _______________________________
Valid Until:
_______________________________
PNA No. :
_______________________________
Valid Until:
_______________________________

ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________

Signature over printed name of Dean
Date signed:
______________________________________
Degree:
Doctor of Philosophy Major in Educational Management
PRC Lic. No. : 78564_________________________________
Valid Until:
September 24, 2014_____________________
PNA No. :
2159__________________________________
Valid Until:
Lifetime_______________________________
ADPCN No. : 11-351________________________________
Valid Until:
May 31, 2012___________________________

FAR EASTERN UNIVERSITY

Nicanor Reyes Sr. Street Sampaloc Manila 1008
Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
PAASCU, Level II Re-Accredited, May 2011
MINOR SURGICAL SCRUB in _________________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _________________________________________
Date Performed
and
Time Started

Patients INITIALS (only)

SURGICAL PROCEDURE
PERFORMED

Case Number

O.R. Nurse on Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Noted by:

Concurred by:

Approved by:

MONICA C. LAGONOY - AONUEVO, RN, MAN__

Signature over printed name of Clinical Coordinator
Date signed:
____________________________
Degree:
Master of Arts in Nursing
__
PRC Lic. No. : 0158815
__
Valid Until:
May 4, 2013__________________
PNA No. :
2011-041254_________________
Valid Until:
December 2012_______________

___________________________________________
Signature over printed name of Chief Nurse
Date signed: _______________________________
Degree:
_______________________________
PRC Lic. No.: _______________________________
Valid Until:
_______________________________
PNA No. :
_______________________________
Valid Until:
_______________________________

ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________

Signature over printed name of Dean
Date signed:
______________________________________
Degree:
Doctor of Philosophy Major in Educational Management
PRC Lic. No. : 78564_________________________________
Valid Until:
September 24, 2014_____________________
PNA No. :
2159__________________________________
Valid Until:
Lifetime_______________________________
ADPCN No. : 11-351________________________________
Valid Until:
May 31, 2012___________________________

FAR EASTERN UNIVERSITY

Nicanor Reyes Sr. Street Sampaloc Manila 1008
Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
PAASCU, Level II Re-Accredited, May 2011
ACTUAL DELIVERY in _______________________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _________________________________________
Date Performed
and
Time Started

Patients INITIALS (only)

PROCEDURE PERFORMED
ASSISTED DELIVERY

Case Number
(Not applicable for Birthing/Lying-In Clinics/Homes)

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty,
Signature not Required)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Noted by:

Concurred by:

Approved by:

MONICA C. LAGONOY - AONUEVO, RN, MAN__

Signature over printed name of Clinical Coordinator
Date signed:
____________________________
Degree:
Master of Arts in Nursing
__
PRC Lic. No. : 0158815
__
Valid Until:
May 4, 2013__________________
PNA No. :
2011-041254_________________
Valid Until:
December 2012_______________

___________________________________________
Signature over printed name of Chief Nurse
Date signed: _______________________________
Degree:
_______________________________
PRC Lic. No.: _______________________________
Valid Until:
_______________________________
PNA No. :
_______________________________
Valid Until:
_______________________________

ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________

Signature over printed name of Dean
Date signed:
______________________________________
Degree:
Doctor of Philosophy Major in Educational Management
PRC Lic. No. : 78564_________________________________
Valid Until:
September 24, 2014_____________________
PNA No. :
2159__________________________________
Valid Until:
Lifetime_______________________________
ADPCN No. : 11-351________________________________
Valid Until:
May 31, 2012___________________________

FAR EASTERN UNIVERSITY

Nicanor Reyes Sr. Street Sampaloc Manila 1008
Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
PAASCU, Level II Re-Accredited, May 2011
IMMEDIATE NEWBORN CARE in ______________________________________________________________
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student _________________________________________
Date Performed
and
Time Started

Patients INITIALS (only)

Case Number

Immediate Newborn Cord Care

PERFORMED

(Not applicable for Birthing/Lying-In Clinics/Homes)

Indicate where performed e.g. D.R., Nursery, NICU, or Home

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty,
Signature not Required)

SUPERVISED BY
Clinical Instructor
(Name and Signature)

Noted by:

Concurred by:

Approved by:

MONICA C. LAGONOY - AONUEVO, RN, MAN__

Signature over printed name of Clinical Coordinator
Date signed:
____________________________
Degree:
Master of Arts in Nursing
__
PRC Lic. No. : 0158815
__
Valid Until:
May 4, 2013__________________
PNA No. :
2011-041254_________________
Valid Until:
December 2012_______________

___________________________________________
Signature over printed name of Chief Nurse
Date signed: _______________________________
Degree:
_______________________________
PRC Lic. No.: _______________________________
Valid Until:
_______________________________
PNA No. :
_______________________________
Valid Until:
_______________________________

ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________

Signature over printed name of Dean
Date signed:
______________________________________
Degree:
Doctor of Philosophy Major in Educational Management
PRC Lic. No. : 78564_________________________________
Valid Until:
September 24, 2014_____________________
PNA No. :
2159__________________________________
Valid Until:
Lifetime_______________________________
ADPCN No. : 11-351________________________________
Valid Until:
May 31, 2012___________________________