1

UNIVERSITY OF PANGASINAN
PHINMA Education Network
College of Nursing
Dagupan City

CIRCULATING CASE SLIP

Name of Student
___________________________

Student Number
PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN, EdD
Clinical Coordinator
PRC NO: 0133422
PNA NO: 02620
ANSAP NO:

VALID UNTIL: July 27, 2014

.
VALID UNTIL: October 31, 2012
.VALID UNTIL:
..

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________
Agency: _____________________________________________

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________

Name of Patient:_____________________ __________________

Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________

Agency: _____________________________________________

Agency: _____________________________________________

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________
Agency: _____________________________________________

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________
Agency: _____________________________________________

1
UNIVERSITY OF PANGASINAN
PHINMA Education Network
College of Nursing
Dagupan City

SCRUB CASE SLIP

Name of Student
___________________________

Student Number
PROF. ZENAIDA M. BAUTISTA BSN-RN, MAN, EdD
Clinical Coordinator
PRC NO: 0133422
PNA NO: 02620
ANSAP NO:

VALID UNTIL: July 27, 2014

.
VALID UNTIL: October 31, 2012
.VALID UNTIL:
.

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________
Agency: _____________________________________________

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________

Name of Patient:_____________________ __________________

Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________

Agency: _____________________________________________

Agency: _____________________________________________

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________
Agency: _____________________________________________

Name of Patient:_______________________________________
Address: _____________________________________________
Age: _______ Sex: _________ Ward: _____________________
Case No: ______________________ Date: _________________
Pre-Op Diagnosis: _____________________________________
____________________________________________________
Post-Op Diagnosis: ____________________________________
____________________________________________________
Operation Performed: __________________________________
____________________________________________________
Time Started: _____________ Time Finished: _______________
Surgeon: _____________________________________________
Assistant: ____________________________________________
Anesthesiologist: ______________________________________
Type of Anesthesia: ____________________________________
Medicine Used: _______________________________________
Anesthesia Started: ____________________________________
Instrument Nurse: _____________________________________
Sponge Nurse: ________________________________________
_________________________
_____________________
Staff Nurse on Duty
Nurse Instructor
PRC No. __________
PRC No. ___________
Agency: _____________________________________________