ODC Form 1

O.R. SCRUB FORM

LPU - ST. CABRINI COLLEGE OF ALLIED MEDICINE, INC Major
Maharlika Highway, Sto Tomas, Batangas
(043) 778 – 6107
ISO 9001 – 2008 ACCREDITED
ISO 9001-2008 SURGICAL SCRUB IN _Batangas Regional Hospital, Batangas City______________
Cert No: CI/4648
Hospital/Municipality/City/Province

Prepared by:
Name of Student __FERRER, KEVIN LANDICHO________ Signature of Student ___________________________________

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

and PROCEDURE PERFORMED Clinical Instructor
Time Started Case Number Name and Signature

11/30/2010 M.B. Laparotomy Cholecystectomy w/ IOC Salve delas Alas Teodorico B. Laurel, RN, MAN
10:20am 467566 Choledochoscopy CBDE T. tube drain

12/2/2010 E.R. Total Abdominal Hysterectomy Allan Hernandez Teodorico B. Laurel, RN, MAN
1:07pm 466440

Noted by: __________REYNALYN M. BUENAOBRA_______________ Concurred by: _______ AMOR CALAYAN_____________

Clinical Coordinator Chief Nurse
PRC I.D No. _0239014____ Valid Until __February 01, 2012 PRC I.D No. _151514__ Valid Until _August 03, 2013_
PNA No. _2011-023897____ Valid Until __October 31, 2011______________ PNA No. _______________________ Valid Until _October 31, 2011________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN, PhD

Approved by: ________ DAISY A. VICENCIO__________________

Dean
PRC I.D No. _0119313___ Valid Until _April 03, 2012 _
PNA No. _2011-023896____ Valid Until _October 31, 2011___________
ADPCN No. _18599 ____________ Valid Until _ May 31, 2012 ____
Date document is signed: _________________________ Time ___________________
Please specify Highest Nursing Degree Earned: MAN
 ODC Form 1
O.R. SCRUB FORM
LPU - ST. CABRINI COLLEGE OF ALLIED MEDICINE, INC Minor
Maharlika Highway, Sto Tomas, Batangas
(043) 778 – 6107
ISO 9001 – 2008 ACCREDITED
ISO 9001-2008 SURGICAL SCRUB IN _ Batangas Regional Hospital, Batangas City _____________
Cert No: CI/4648
Hospital/Municipality/City/Province

Prepared by:
Name of Student __FERRER, KEVIN LANDICHO________ Signature of Student ___________________________________

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

and PROCEDURE PERFORMED Clinical Instructor
Time Started Case Number Name and Signature

7/19/2010 F.M. Suturing, mandible Ian Lester P. Calangi Ana Lissa G. Ilagan, RN
4:05am 452575

7/21/2010 K.M.R. Suturing, Frontal Aries Thomas Luna Ana Lissa G. Ilagan, RN
5:10am 452880

Noted by: __________REYNALYN M. BUENAOBRA_______________ Concurred by: _______ AMOR CALAYAN_____________

Clinical Coordinator Chief Nurse
PRC I.D No. _0239014____ Valid Until __February 01, 2012 PRC I.D No. _151514__ Valid Until _August 03, 2013_
PNA No. _2011-023897____ Valid Until __October 31, 2011______________ PNA No. _______________________ Valid Until _October 31, 2011________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN, PhD

Approved by: ________ DAISY A. VICENCIO__________________

Dean
PRC I.D No. _0119313___ Valid Until _April 03, 2012 _
PNA No. _2011-023896____ Valid Until _October 31, 2011___________
ADPCN No. _18599 ____________ Valid Until _ May 31, 2012 ____
Date document is signed: _________________________ Time ___________________
Please specify Highest Nursing Degree Earned: MAN
 ODC Form 2
ACTUAL DELIVERY FORM
LPU - ST. CABRINI COLLEGE OF ALLIED MEDICINE, INC
Maharlika Highway, Sto Tomas, Batangas
(043) 778 – 6107
ISO 9001 – 2008 ACCREDITED
ISO 9001-2008 ACTUAL DELIVERY in __Batangas Regional Hospital, Batangas City_______________
Cert No: CI/4648
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Student __FERRER, KEVIN LANDICHO________ Signature of Student ___________________________________

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

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

9/3/2010 I.J.
5:49am 456888 Normal Spontaneous Delivery Alma Zaraspe Ana Lissa G. Ilagan, RN
2/16/2010 A.U.
1:30pm 426633 Normal Spontaneous Delivery Melva Cleotilde Remo Ana Lissa G. Ilagan, RN
2/18/2010 B.C.
2:17pm 30292 Normal Spontaneous Delivery Mila Engay Ana Lissa G. Ilagan, RN
10/5/2010 E.N.
12:37pm 460779 Normal Spontaneous Delivery Rachelle Laco Ana Lissa G. Ilagan, RN

Noted by: __________REYNALYN M. BUENAOBRA_______________ Concurred by: _______ AMOR CALAYAN_____________

Clinical Coordinator Chief Nurse
PRC I.D No. _0239014____ Valid Until __February 01, 2012 PRC I.D No. _151514__ Valid Until _August 03, 2013_
PNA No. _2011-023897____ Valid Until __October 31, 2011______________ PNA No. _______________________ Valid Until _October 31, 2011________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN, PhD

Approved by: ________ DAISY A. VICENCIO__________________

Dean
PRC I.D No. _0119313___ Valid Until _April 03, 2012 _
PNA No. _2011-023896____ Valid Until _October 31, 2011___________
ADPCN No. _18599 ____________ Valid Until _ May 31, 2012 ____
Date document is signed: _________________________ Time ___________________
Please specify Highest Nursing Degree Earned: MAN
 LPU - ST. CABRINI COLLEGE OF ALLIED MEDICINE, INC ODC Form 3
Maharlika Highway, Sto Tomas, Batangas D.R. ASSIST FORM
(043) 778 – 6107
ISO 9001 – 2008 ACCREDITED
ISO 9001-2008 ASSISTED DELIVERY in Batangas Regional Hospital Batangas City_________________
Cert No: CI/4648
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Student __FERRER, KEVIN LANDICHO________ Signature of Student ___________________________________

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

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

8/31/2010 D.E. Normal Spontaneous Delivery Rowena Aclan Ana Lissa G. Ilagan, RN
7:45pm 388518

2/15/2010 G.G. Normal Spontaneous Delivery Melva Cleotilde Remo Ana Lissa G. Ilagan, RN
12:14pm 445778

10/1/2010 G.M. Normal Spontaneous Delivery Rachelle Laco Ana Lissa G. Ilagan, RN
9:12am 325198

Noted by: __________REYNALYN M. BUENAOBRA_______________ Concurred by: _______ AMOR CALAYAN_____________

Clinical Coordinator Chief Nurse
PRC I.D No. _0239014____ Valid Until __February 01, 2012 PRC I.D No. _151514__ Valid Until _August 03, 2013_
PNA No. _2011-023897____ Valid Until __October 31, 2011______________ PNA No. _______________________ Valid Until _October 31, 2011________
Date document is signed: _________________________ Time __________________ Date document is signed: _________________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN Please specify Highest Nursing Degree Earned: MAN, PhD

Approved by: ________ DAISY A. VICENCIO__________________

Dean
PRC I.D No. _0119313___ Valid Until _April 03, 2012 _
PNA No. _2011-023896____ Valid Until _October 31, 2011___________
ADPCN No. _18599 ____________ Valid Until _ May 31, 2012 ____
Date document is signed: _________________________ Time ___________________
Please specify Highest Nursing Degree Earned: MAN