2010 Template of Cases BRH

ODC Form 1
STI COLLEGE STA.CRUZ O.R. SCRUB FORM

Major
1522 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna
(049) 501-3446
SURGICAL SCRUB IN: BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Hospital/Municipality/City/Province
Prepared by:
Date Performed Patient’s Initial O.R. Nurse On SUPERVISED BY
and
Case Number
PROCEDURE Duty Clinical Instructor
Time Started Name and Signature
PERFORMED
Teodorico Laurel R.N., M.A.N.

Name of Student ______________________________________________ Signature of Student

___________________________________
BERNADETTE B. APOLO
Noted by: Concurred by: AMOR B.
CALAYAN
Clinical Coordinator Chief Nurse
PRC I.D No. 0084557 Valid Until: November 11, 2011 PRC I.D No. 151514 Valid Until: August 3, 2013
PNA No. 14922 Valid Until: Lifetime PNA No. 2011-048006 Valid Until: October 31, 2011
Date document is signed: _________________ Time ___________ Date document is signed: _______________ Time: ____________
Please specify Highest Nursing Degree Earned: M.A.N. Please specify Highest Nursing Degree Earned: M.A.N, PhD
Approved by: FRANCISCA R. ARELLANO

Dean
PRC I.D No.0056168 Valid Until: March 2012
PNA No. 2011-032081 Valid Until October 31, 2011
Date document is signed: ________________ Time __________
Highest Nursing Degree Earned: M.A.N.
ODC Form 1
STI COLLEGE STA.CRUZ O.R. SCRUB FORM
Minor
(049) 808-3446
SURGICAL SCRUB IN: BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Hospital/Municipality/City/Province
Prepared by:
Name of Student ______________________________________________ Signature of Student ___________________________________
Date Performed Patient’s Initial O.R. Nurse On SUPERVISED BY

and
Case Number
PROCEDURE Duty Clinical Instructor
Time Started Name and Signature
PERFORMED
Teodorico Laurel R.N., M.A.N..

BERNADETTE B. APOLO
CALAYAN
Dean
ODC Form 2
STI COLLEGE STA.CRUZ ACTUAL DELIVERY
FORM
(049) 808-3446
ACTUAL DELIVERY in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas
Hospital/Home/Lying-In Clinic,
Municipality/City/Province
Prepared by:
Name of Student ___________________________________________ Signature of Student _______ _____________________________
Date Performed Patient’s Initial PROCEDURE D.R. Nurse on SUPERVISED BY

and PERFORMED Duty Clinical Instructor
Time Started Case Number Name and Signature
(not applicable for
Birthing/Lying-In
Clinics/Homes)
Gonzala B. De Mesa R.N., M.A.N


BERNADETTE B. APOLO
CALAYAN

Dean
STI COLLEGE STA.CRUZ ODC Form 3

D.R. ASSIST
FORM
(049) 808-3446
ASSISTED DELIVERY in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas
Prepared by:
Name of Student _________________________________________ Signature of Student ___________________________________
Date Performed Patient’s Initial PROCEDURE D.R. Nurse On SUPERVISED BY

and Case Number PERFORMED Duty Clinical Instructor
Time Started (not applicable for Name and Signature
Birthing /Lying-In
Clinics/Homes)

BERNADETTE B. APOLO
CALAYAN

Dean
ODC Form 4
STI COLLEGE STA.CRUZ D.R. IMMEDIATE
NEWBORN
1544 Lord’s Grace Building, P. Guevarra Avenue, Sta. Cruz, Laguna CORD CARE FORM
(049) 808-3446
IMMEDIATE NEWBORN CORD CARE in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas
Prepared by:
Name of Student ________________________________________ Signature of Student _________________________________________
Date Performed Patient’s Initial Immediate Newborn Cord Nurse On SUPERVISED BY

and Care PERFORMED Duty Clinical Instructor
Time Started Case Number Name and Signature
(not applicable for Indicate where performed e.g.
Birthing Homes/Lying-In D.R., Nursery, NICU, or Home
Clinics/Homes)
Bernadette B. Apolo R.N., M.A.N


BERNADETTE B. APOLO
CALAYAN

Dean

2010 Template of Cases BRH

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2010 Template of Cases BRH

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ODC Form 1

STI COLLEGE STA.CRUZ O.R. SCRUB FORM

SURGICAL SCRUB IN: BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Teodorico Laurel R.N., M.A.N.

Teodorico Laurel R.N., M.A.N.

Name of Student ______________________________________________ Signature of Student

Approved by: FRANCISCA R. ARELLANO

SURGICAL SCRUB IN: BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Name of Student ______________________________________________ Signature of Student ___________________________________

Date Performed Patient’s Initial O.R. Nurse On SUPERVISED BY

Teodorico Laurel R.N., M.A.N..

Teodorico Laurel R.N., M.A.N.

Teodorico Laurel R.N., M.A.N.

ACTUAL DELIVERY in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Name of Student ___________________________________________ Signature of Student _______ _____________________________

Date Performed Patient’s Initial PROCEDURE D.R. Nurse on SUPERVISED BY

Gonzala B. De Mesa R.N., M.A.N

Gonzala B. De Mesa R.N., M.A.N

Approved by: FRANCISCA R. ARELLANO

STI COLLEGE STA.CRUZ ODC Form 3

ASSISTED DELIVERY in BATANGAS REGIONAL HOSPITAL, Batangas City, Batangas

Name of Student _________________________________________ Signature of Student ___________________________________

Date Performed Patient’s Initial PROCEDURE D.R. Nurse On SUPERVISED BY

Gonzala B. De Mesa R.N., M.A.N

Approved by: FRANCISCA R. ARELLANO

Name of Student ________________________________________ Signature of Student _________________________________________

Date Performed Patient’s Initial Immediate Newborn Cord Nurse On SUPERVISED BY

Bernadette B. Apolo R.N., M.A.N

Bernadette B. Apolo R.N., M.A.N

Bernadette B. Apolo R.N., M.A.N

Approved by: FRANCISCA R. ARELLANO

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