Scribd
Upload
55 views3 pages

AMA School of Medicine: Marcos Highway Brgy. Mayamot, Antipolo City, Rizal

This document contains forms from the AMA School of Medicine for documenting actual deliveries, assisted deliveries, and immediate newborn cord care performed by students. The forms require documentation of the date, time, student and supervisor information, patient information, procedure performed, and signatures of the clinical coordinator, chief nurse, and dean to verify the documented activities. Signatures of only the clinical instructor and clinical coordinator are needed for deliveries performed in lying-in clinics or homes.

Uploaded by

April Kramer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
55 views3 pages

AMA School of Medicine: Marcos Highway Brgy. Mayamot, Antipolo City, Rizal

This document contains forms from the AMA School of Medicine for documenting actual deliveries, assisted deliveries, and immediate newborn cord care performed by students. The forms require documentation of the date, time, student and supervisor information, patient information, procedure performed, and signatures of the clinical coordinator, chief nurse, and dean to verify the documented activities. Signatures of only the clinical instructor and clinical coordinator are needed for deliveries performed in lying-in clinics or homes.

Uploaded by

April Kramer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 3

AMA School of Medicine Marcos Highway Brgy. Mayamot, Antipolo City, Rizal 249-1261, 249-1741, www.amaes.edu.

ph CHED Recognition # 038, Series of 2007, April 25, 2007 ACTUAL DELIVERY in (Name of Hospital)
(Address)

ODC Form 3 ACTUAL DELIVERY FORM

Prepared by: Name of Student: __________________________


Date Performed and Time Started Patients Name

Signature of Student: ______________________


PROCEDURE PERFORMED D. R. NURSE / MIDWIFE ON DUTY SUPERVISED BY Clinical Instructor / Name and Signature

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

Noted by: ___________JULIET B. BATAC_______________ Print Name and Signature of Clinical Coordinator PRC No: 0193891 Valid Until: July 30, 2011 PNA No. 2011-046405 Valid Until: October 31, 2011 Date Document is signed: ____________ Time : __________ Highest Degree Earned: RN, MAN

Concurred by: ________________________________________ Print Name and Signature of Chief Nurse PRC ID No.: 0085225 Valid Until: February 19, 2013 PNA No. 16782 _ Valid Until: Lifetime Member ANSAP No: 1588___ Valid Until: Lifetime Member Date Document is signed: __________________ Time : ___________ Highest Degree Earned: RN, RM, MAN, PhD.

Approved by : ___LAVINIA D. PANGANIBAN___ Print Name and Signature of Dean PRC No.: 0040385 Valid Until: December 12, 2013 ADPCN No: 163 Valid Until: March 2011 PNA No. 17252 Valid Until: Lifetime Member Date Document is signed: ____________ Time : ________ Highest Degree Earned: RN, RM, MAN, Ed.D
For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are required to sign.

AMA School of Medicine Marcos Highway Brgy. Mayamot, Antipolo City, Rizal 249-1261, 249-1741, www.amaes.edu.ph CHED Recognition # 038, Series of 2007, April 25, 2007 ASSISTED DELIVERY in (Name of Hospital)
(Address)

ODC Form 3 D. R. ASSIST FORM

Prepared by: Name of Student: _____________________________


Date Performed and Time Started

Signature of Student: ______________________


D. R. NURSE / MIDWIFE ON DUTY SUPERVISED BY Clinical Instructor / Name and Signature

Patients Name Case Number


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

PROCEDURE PERFORMED

Noted by:

___________JULIET B. BATAC_______________ Print Name and Signature of Clinical Coordinator PRC ID No: 0193891 Valid Until: July 30, 2011 PNA No. 2011-046405 Valid Until: October 31, 2011 Date Document is signed: __________________ Time : ______________ Highest Degree Earned: RN, MAN

Concurred by: ___________________________________ Print Name and Signature of Chief Nurse PRC ID No.: 0085225 Valid Until: February 19, 2013 PNA No. 16782 _ Valid Until: Lifetime Member ANSAP No: 1588___ Valid Until: Lifetime Member Date Document is signed: __________________ Time : ___________ Highest Degree Earned: RN, RM, MAN, PhD.

Approved by : ___ LAVINIA D. PANGANIBAN___ Print Name and Signature of Dean PRC ID No.: 0040385 Valid Until: December 12, 2013 ADPCN No: 163 Valid Until: March 2011 PNA No. 17252 Valid Until: Lifetime Member Date Document is signed: __________________ Time : _________ Highest Degree Earned: RN, RM, MAN, Ed.D

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are required to sign.

AMA School of Medicine Marcos Highway Brgy. Mayamot, Antipolo City, Rizal 249-1261, 249-1741, www.amaes.edu.ph CHED Recognition # 038, Series of 2007, April 25, 2007 Immediate Newborn Cord Care in (Name of Hospital)
(Address)

ODC Form 4 D. R. IMMEDIATE NEWBORN CORD CARE FORM

Prepared by: Name of Student: ____________________________


Date Performed and Time Started

Signature of Student: ______________________


NURSE / MIDWIFE ON DUTY SUPERVISED BY Clinical Instructor / Name and Signature

Patients Name Case Number


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

Immediate Newborn Cord Care PERFORMED


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

Noted by: ___________JULIET B. BATAC_______________ Print Name and Signature of Clinical Coordinator PRC ID No: 0193891 Valid Until: July 30, 2011 PNA No. 2011-046405 Valid Until: October 31, 2011 Date Document is signed: __________________ Time : ______________ Highest Degree Earned: RN, MAN

Concurred by: ________________________________ Print Name and Signature of Chief Nurse PRC ID No.: ____ Valid Until: PNA No. _ Valid Until: ANSAP No: ___ Valid Until: Date Document is signed: __________________ Time : ___________ Highest Degree Earned: RN, MAN-c

Approved by : ___ LAVINIA D. PANGANIBAN___ Print Name and Signature of Dean PRC ID No.: 0040385 Valid Until: December 12, 2013 ADPCN No: 163 Valid Until: March 2011 PNA No. 17252 Valid Until: Lifetime Member Date Document is signed: __________________ Time : _________ Highest Degree Earned: RN, RM, MAN, Ed.D

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are required to sign.

You might also like