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CIRCU

This document is an operating room circulating form from Western Mindanao State University. It provides fields to record information about a student nurse's observation and participation in a surgical procedure, including the student's name, the date and time of the procedure, identifying information for the patient, the surgical procedure performed, and signatures of the operating room nurse on duty and clinical instructor supervising the student.

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Fatima C. Fernandez
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© Attribution Non-Commercial (BY-NC)
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Download as DOC, PDF, TXT or read online on Scribd
33 views

CIRCU

This document is an operating room circulating form from Western Mindanao State University. It provides fields to record information about a student nurse's observation and participation in a surgical procedure, including the student's name, the date and time of the procedure, identifying information for the patient, the surgical procedure performed, and signatures of the operating room nurse on duty and clinical instructor supervising the student.

Uploaded by

Fatima C. Fernandez
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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O.R.

Form 1B

WESTERN MINDANAO STATE UNIVERSITY Normal Road, Baliwasan, Zamboanga City, Philippines
Telephone No. (062) 992-0315 / Fax No. (062) 992-4238 / E-mail: cn@wmsu.edu.ph / Web-Site: www.wmsu.edu.ph

O.R. CIRCULATING FORM

Accredited by: Accrediting Agencies of Chartered Colleges and Universities in the Philippines / Level II Re-accredited / February 2009 CIRCULATING in ______________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by: Printed Name with Signature of Student:


Date Performed and Time Started Patients INITIALS only Case Number

FERNANDEZ, JOBELLINE MAE C._

(not applicable for Birthing /Lying In Clinics / Homes)

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY: Clinical Instructor Name and Signature

Noted by: SARAH S. TAUPAN, R.N., M.N. ,D.P.A Clinical Coordinator, PRC I.D. No. 0150766 Valid Until: January 17, 2015
Date document is signed: Please specify Highest Nursing Degree Earned: Time: Master in Nursing _______

Approved by:___________________________________________________ OIC-Dean, PRC I.D. No._______ __ Valid Until: _______________ __________
Date document is signed: Specify Highest Nursing Degree Earned: Time: _______
_____________________________

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