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DR Forms 3 Tiers

Lecture notes

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estampadorlucyl20
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7 views

DR Forms 3 Tiers

Lecture notes

Uploaded by

estampadorlucyl20
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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DR Form 1A

UNIVERSITY OF ILOILO ACTUAL DELIVERY FORM


Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ACTUAL DELIVERY in __________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Patient’s Initial Only D.R. Nurse on Duty SUPERVISED BY


Date Performed Case Number PROCEDURE (Name and Signature) Clinical Instructor
and (not applicable for Birthing/Lying-In PERFORMED (If Midwife on Duty, (Name and Signature)
Time Started Clinics/Homes) signature not required)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________


(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No.:_____________________Valid Until:________________ Dean, PRC I.D. No.:_____________________________Valid Until:______________________
Date document is signed:___________________________Time:_____________________ Date document is signed:________________________ Time:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:_____________________________________________
ICNB Form
UNIVERSITY OF ILOILO IMMEDIATE CARE OF THE
Rizal Street, Iloilo City NEWBORN FORM
Tel. No. (033) 338-1071 loc. 146

ACTUAL DELIVERY in __________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Patient’s Initial Only IMMEDIATE NEWBORN CORD CARE D.R. Nurse on Duty SUPERVISED BY
Date Performed Case Number PERFORMED (Name and Signature) Clinical Instructor
and (not applicable for Birthing/Lying-In (Indicate where performed e.g. DR, (If Midwife on Duty, (Name and Signature)
Time Started Clinics/Homes) Nursery or NICU or Home) signature not required)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________


(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No.:_____________________Valid Until:________________ Dean, PRC I.D. No.:_____________________________Valid Until:______________________
Date document is signed:___________________________Time:_____________________ Date document is signed:________________________ Time:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:_____________________________________________
DR Form 1B
UNIVERSITY OF ILOILO ASSISTED DELIVERY FORM
Rizal Street, Iloilo City
Tel. No. (033) 338-1071 loc. 146

ACTUAL DELIVERY in __________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student___________________________________________________________

Patient’s Initial Only D.R. Nurse on Duty SUPERVISED BY


Date Performed Case Number PROCEDURE (Name and Signature) Clinical Instructor
and (not applicable for Birthing/Lying-In PERFORMED (If Midwife on Duty, (Name and Signature)
Time Started Clinics/Homes) signature not required)

Noted by:_________________________________________________________________ Approved by:_________________________________________________________________


(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No.:_____________________Valid Until:________________ Dean, PRC I.D. No.:_____________________________Valid Until:______________________
Date document is signed:___________________________Time:_____________________ Date document is signed:________________________ Time:__________________________
Please specify Highest Degree Earned:__________________________________________ Please specify Highest Degree Earned:_____________________________________________

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