New PRC Form

ODC Form 1AO.R. Scrub Form Major

FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 ACTUAL DELIVERY In___________________________________________________ Hospital,Municipality/City/Province Prepared by: Printed Name with Signature of Student________________________________________________ Date Performed And Time Started Patients INITIAL onlyCase Number(not applicable for Birthing/ Lying-in Clinics/ Homes)

SURGICAL PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature) (If Midwife On Duty,Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by:______________________________________________________ (Print Name and Signature)Clinical Coordinator, PRC, ID No._____________________________Valid Until_______________ Date document is signed: _________________________________ Time:____________________ Please specify Highest Nursing Degree Earned: _________________________________________

Approved by:_________________________________ (Print Name and Signature)Dean, PRC, ID No.__________________ Valid Until _______________ Date document is signed: ________________Time:_______________ Specify Highest Nursing Degree Earned: _______________________

(STRICTLY NO DESIGNATES)


FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 SURGICAL SCRUB InCastro General & Maternity Hospital Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of StudentCantal, Andrea Rose L. Date Performed And Time StartedJuly 26, 2010; 9:30am

Patients INITIAL onlyCase Number N.I.G.R; 10-07-2739

SURGICAL PROCEDURE PERFORMEDRTCS II

D.R. Nurse On Duty (Name and Signature)Evelyn and Pam

SUPERVISED BY Clinical Instructor Name and SignatureMs. Glenda Santos





FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 SURGICAL SCRUB InDr. Fe Del Mundo Medical Center Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of StudentCantal, Andrea Rose L. Date Performed And Time StartedOctober 6, 2010; 11:28am

Patients INITIAL onlyCase Number L.E; 10242

SURGICAL PROCEDURE PERFORMEDCaesarean Section

D.R. Nurse On Duty (Name and Signature)Nievas Adjarani

SUPERVISED BY Clinical Instructor Name and SignatureMs. Donna Cruz




ODC Form 2BO.R. MINOR FORM

FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 SURGICAL SCRUB In Dr. Fe Del Mundo Medical Center Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of StudentCantal, Andrea Rose L. Date Performed And Time StartedSeptember 22, 2010; 7am September 23, 2010; 11:40am

Patients INITIAL onlyCase Number F.M; 899 P.U; 894

SURGICAL PROCEDURE PERFORMEDProctoscopy Excision of Perianal Mass

D.R. Nurse On Duty (Name and Signature)Casey De Guzman Manolito Aban

SUPERVISED BY Clinical Instructor Name and SignatureMrs. Donna Cruz Mrs. Donna Cruz




ODC Form 2BO.R. MINOR FORM

FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 SURGICAL SCRUB In Jose Reyes Memorial Medical Center Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of StudentCantal, Andrea Rose L. Date Performed And Time StartedJuly 07, 2011; 8:30am

Patients INITIAL onlyCase Number J.L.R; 651001

SURGICAL PROCEDURE PERFORMEDSuturing

D.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and SignatureMrs. Veronica Dancil




ODC Form 1CCORD CARE FORM

FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 IMMEDIATE NEWBORN CORD CARE In___________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student________________________________________________ Date Performed And Time Started Patients INITIAL onlyCase Number(not applicable for Birthing/ Lying-in Clinics/ Homes)

IMMEDIATE NEWBORN CORD CAREPERFORMEDIndicate 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)





ODC Form 1BASSISTED DELIVERY FORM

FAR EASTERN UNIVERSITY Nicanor Reyes Sr. Street Sampaloc, Manila 1008 Tel.No (632)735-8713: Fax No.736-0010/ [email protected], www.feu.edu.ph PAASCU, Level II, May 2011 ACTUAL DELIVERY In___________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student________________________________________________ Date Performed And Time Started Patients INITIAL onlyCase Number(not applicable for Birthing/ Lying-in Clinics/ Homes)

PROCEDURE PERFORMEDASSISTED DELIVERY

D.R. Nurse On Duty (Name and Signature)(If Midwife On Duty, Signature Not Required)





New PRC Form

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