Guiwan Main Health Center and Lying-In Clinic, Zamboanga City

D.R.
FORM
ACTUAL DELIVERY
ATENEO DE ZAMBOANGA UNIVERSITY FORM
La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED/ Accredited Level III/ Year Granted: May 20, 2014-2019
ACTUAL DELIVERY in GUIWAN MAIN HEALTH CENTER AND LYING-IN CLINIC, ZAMBOANGA CITY
Hospital, Lying-in Center, Municipality/ City/ Province
Prepared by:
Name of Student: MARQUEZ, MARIA THERESE MENDOZA Signature of Student: __________________________
Date Performed Patient’s Name SUPERVISED BY:

Nurse On Duty
and NATURE OF DELIVERY Name and Signature
Clinical Instructor
Time Started Name and Signature
Case Number
November 13, 2019 L. G. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A. GONZAGA,
6:30 A.M. 20-2319 DELIVERY RN, MN
Noted by: Approved by:

ARACELI SEMILLA-PISON, RN, MSPH MARIA LORNA BELLO-PABER, RN, MAN
Clinical Coordinator Dean
PRC I.D. No. 0155451 Valid Until: 2020 PRC I.D. No. 0059150 Valid Until: 2022
PNA I.D. No. 012468 Valid Until: 2019 PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2020
Date document is signed: _______________________ Time: ______________ Date document is signed: ____________________Time: __________
Highest Degree Earned: MASTER OF SCIENCE IN PUBLIC HEALTH Highest Degree Earned: MASTER OF ARTS IN NURSING
D.R. FORM
ACTUAL DELIVERY
Prepared by:
Name of Student: MARQUEZ, MARIA THERESE MENDOZA Signature of Student: ________________________

Nurse On Duty
Clinical Instructor
Case Number
December 2, 2019 B. G. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A GONZAGA


ICNB Form
IMMEDIATE CARE OF
ATENEO DE ZAMBOANGA UNIVERSITY THE NEWBORN FORM
IMMEDIATE NEWBORN CORD CARE in GUIWAN MAIN HEALTH CENTER AND LYING-IN CLINIC, ZAMBOANGA CITY
Hospital, Municipality/ City/ Province
Prepared by:
Name of Student: MARQUEZ, MARIA THERESE MENDOZA Signature of Student: ___________________________
Patient’s Name SUPERVISED BY:

IMMEDIATE NEWBORN CORD Nurse On Duty
Date Performed Clinical Instructor
CARE PERFORMED Name and Signature
Name and Signature
Case Number
December 16, 2019 Baby Girl L. CORD CARE DELIVERY ROOM LULU N. BELLO MODESTA A. GONZAGA,
19-2194 RN, MN

ICNB Form
IMMEDIATE CARE OF
Prepared by:

Name and Signature
Case Number
December 26,2019 Baby Boy P. CORD CARE DELIVERY ROOM LULU N. BELLO MODESTA A. GONZAGA,
19-2251 RN, MN

ICNB Form
IMMEDIATE CARE OF
Prepared by:

Name and Signature
Case Number
November 25, 2019 Baby Girl F. CORD CARE DELIVERY ROOM LULU N. BELLO MODESTA A. GONZAGA,
14-1253 RN, MN
ICNB Form
IMMEDIATE CARE OF
Prepared by:

Name and Signature
Case Number
November 26, 2019 Baby Girl V. CORD CARE DELIVERY ROOM LULU N. BELLO MODESTA A. GONZAGA,
11-337 RN, MN
D.R. FORM
ASSISTED DELIVERY
FORM
ATENEO DE ZAMBOANGA UNIVERSITY
Prepared by:
Name of Student: MARQUEZ, MARIA THERESE MENDOZA Signature of Student: __________________________

Nurse On Duty
Clinical Instructor
Case Number
November 30, 2019 M. G. C. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A. GONZAGA,
2:20 P.M. 19-2073 DELIVERY RN MN

ICNB Form
IMMEDIATE CARE OF
IMMEDIATE NEWBORN CORD CARE in GUIWAN HEALTH CENTER, ZAMBOANGA CITY
Prepared by:
Name of Student: ALIH, MARK EFFENDY BANDAHALA Signature of Student: ___________________________

Name and Signature
Case Number
November 30, 2019 Baby Boy G. CORD CARE DELIVERY ROOM LULU N. BELLO MODESTA A. GONZAGA,
19-2073 RN, MN

ICNB Form
IMMEDIATE CARE OF
Prepared by:
Name of Student: ALIH, MARK EFFENDY BANDAHALA Signature of Student: ___________________________

Name and Signature
Case Number
December 27, 2019 Baby Girl M. CORD CARE DELIVERY ROOM LULU N. BELLO MODESTA A. GONZAGA,
19-2205 RN, MN

D.R. FORM
ACTUAL DELIVERY
Prepared by:
Name of Student: ALIH, MARK EFFENDY BANDAHALA Signature of Student: ________________________

Nurse On Duty
Clinical Instructor
Case Number
November 25, 2019 L. P. F. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A GONZAGA

D.R. FORM
ACTUAL DELIVERY
Prepared by:

Nurse On Duty
Clinical Instructor
Case Number
November 26, 2019 J. V. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A GONZAGA

D.R. FORM
ACTUAL DELIVERY
Prepared by:

Nurse On Duty
Clinical Instructor
Case Number
December 16, 2019 I. L. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A GONZAGA
3:25 P.M. 19-2194 DELIVERY RN, MN
D.R. FORM
ASSISTED DELIVERY
FORM
ATENEO DE ZAMBOANGA UNIVERSITY
Prepared by:
Name of Student: ALIH, MARK EFFENDY BANDAHALA Signature of Student: __________________________

Nurse On Duty
Clinical Instructor
Case Number
November 13, 2019 L. G. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A. GONZAGA,
D.R. FORM
ASSISTED DELIVERY
Prepared by:

Nurse On Duty
Clinical Instructor
Case Number
December 26, 2019 M. P. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A. GONZAGA,
10:20 A.M. 19-2251 DELIVERY RN MN

D.R. FORM
ASSISTED DELIVERY
Prepared by:
Nurse On Duty
Clinical Instructor
Case Number
December 2, 2019 B. G. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A. GONZAGA,

6:20 A.M. 10-110 DELIVERY RN MN


Guiwan Main Health Center and Lying-In Clinic, Zamboanga City

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D.R.

Hospital, Lying-in Center, Municipality/ City/ Province

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Hospital, Lying-in Center, Municipality/ City/ Province

Date Performed Patient’s Name SUPERVISED BY:

December 2, 2019 B. G. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A GONZAGA

Noted by: Approved by:

Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Patient’s Name SUPERVISED BY:

Patient’s Name SUPERVISED BY:

Hospital, Lying-in Center, Municipality/ City/ Province

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

Date Performed Patient’s Name SUPERVISED BY:

Date Performed Patient’s Name SUPERVISED BY:

Hospital, Lying-in Center, Municipality/ City/ Province

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

December 2, 2019 B. G. NORMAL SPONTANEOUS VAGINAL LULU N. BELLO MODESTA A. GONZAGA,

Noted by: Approved by:

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