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DIVINE WORD COLLEGE OF LAOAG SCHOOL OF NURSING

General Segundo Avenue, 2900 Laoag City, Philippines Telephone Number: 772-0736 * 772-1228 * 771-4175 * Fax No. * Website: www.dwcl.edu.ph Accredited by: MAJOR SURGICAL SCRUB in MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER, BATAC CITY, ILOCOS NORTE Prepared by: Date Performed and Time Started JULY 08, 2011 9:25 A.M Patient's Initial Case Number A.B.C 601234 SUPERVISED BY Clinical Instructor (Name & Signature) LESLEE A. EDROZO, RN

SURGICAL PROCEDURE PERFORMED Total Abdominal Hysterectomy Bilateral Salphingo-Oophorectomy

O.R. Nurse On Duty (Name & Signature) OSCAR S. SADORRA, RN

Noted by: GLORIA A. SANCHEZ Clinical Coordinator PRC I.D. NO.: 46805 Valid Until: December 18, 2015 Date Document Signed: Time: Highest Nursing Degree Earned: R.N., M.A.N., Ph.D.

Approved by: IMELDA R. CARLOS Dean PRC I.D. No.: 69952 Valid Until: April 21, 2013 ADCPN No.: 11-089 Valid Until: May 31, 2014 Date Document Signed: Time: Highest Nursing Degree Earned: R.N., M.A.N.

DIVINE WORD COLLEGE OF LAOAG SCHOOL OF NURSING


General Segundo Avenue, 2900 Laoag City, Philippines Telephone Number: 772-0736 * 772-1228 * 771-4175 * Fax No. * Website: www.dwcl.edu.ph Accredited by: MAJOR SURGICAL CIRCULATING in MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER, BATAC CITY, ILOCOS NORTE Prepared by: Date Performed and Time Started Patient's Initial Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name & Signature) SUPERVISED BY Clinical Instructor (Name & Signature)

Noted by: GLORIA A. SANCHEZ Clinical Coordinator PRC I.D. NO.: 46805 Valid Until: December 18, 2015 Date Document Signed: Time: Highest Nursing Degree Earned: R.N., M.A.N., Ph.D.

Approved by: IMELDA R. CARLOS Dean PRC I.D. No.: 69952 Valid Until: April 21, 2013 ADCPN No.: 11-089 Valid Until: May 31, 2014 Date Document Signed: Time: Highest Nursing Degree Earned: R.N., M.A.N.

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