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Jose Rizal University: ODC Form 2A

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JonieP84

This document is an O.R. scrub form from Jose Rizal University documenting a surgical scrub performed by a student. It contains fields to record the date and time of the scrub, the patient's initials and case number, the surgical procedure performed, the O.R. nurse on duty, and the clinical instructor who supervised the scrub. Signatures are required from the student, clinical instructor, and dean to verify the details and approve the document.

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Attribution Non-Commercial (BY-NC)
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Jose Rizal University: ODC Form 2A

Uploaded by

JonieP84
25 views3 pages
This document is an O.R. scrub form from Jose Rizal University documenting a surgical scrub performed by a student. It contains fields to record the date and time of the scrub, the patient's initials and case number, the surgical procedure performed, the O.R. nurse on duty, and the clinical instructor who supervised the scrub. Signatures are required from the student, clinical instructor, and dean to verify the details and approve the document.

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PRC Forms OR Major

Original Title

PRC Forms OR Major

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© Attribution Non-Commercial (BY-NC)

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This document is an O.R. scrub form from Jose Rizal University documenting a surgical scrub performed by a student. It contains fields to record the date and time of the scrub, the patient's initials and case number, the surgical procedure performed, the O.R. nurse on duty, and the clinical instructor who supervised the scrub. Signatures are required from the student, clinical instructor, and dean to verify the details and approve the document.

Copyright:

Attribution Non-Commercial (BY-NC)
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
25 views3 pages

Jose Rizal University: ODC Form 2A

Uploaded by

JonieP84
This document is an O.R. scrub form from Jose Rizal University documenting a surgical scrub performed by a student. It contains fields to record the date and time of the scrub, the patient's initials and case number, the surgical procedure performed, the O.R. nurse on duty, and the clinical instructor who supervised the scrub. Signatures are required from the student, clinical instructor, and dean to verify the details and approve the document.

Copyright:

Attribution Non-Commercial (BY-NC)
Download as DOCX, PDF, TXT or read online from Scribd
Download as docx, pdf, or txt
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ODC Form 2A

O.R. SCRUB FORM


Major

Jose Rizal University

80 Shaw Blvd., Mandaluyong city

Tel: 531-8031 / Fax: 532-1418 / E-mail: jru@jru.edu

Website: www.jru.edu.ph

SURGICAL SCRUB in: _____________________________________________________________________________

Hospital, City / Municipality / Province

Prepared by: _____________________________________________________________________________

Printed name with signature of student

Date Performed and Patient’s Initials (only) and Surgical Procedure Performed OR Nurse on Duty Supervised by

Time Started Case Number (Name and Signature) Clinical Instructor

(Name and Signature)


Noted by: _______________________________________________________ Approved by: _______________________________________________________

Printed Name and Signature Printed Name and Signature

Clinical Instructor, PRC ID no.: ______________________ Valid until: ___________ Dean, PRC ID no.: ______________________ Valid until: ___________

Date document is signed: _________________________ Time: ___________ Date document is signed: _________________________ Time: ___________

Specify Highest Degree Earned: _______________________________________________ Specify Highest Degree Earned: _______________________________________________

(STRICTLY NO DESIGNATES)

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