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    PRC Cases Templateeeeee

    Uploaded by

    Winter Kim
    _____________________________ NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of suturing of perineal lacerations before signing the form. 2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on Suturing of Perineal Laceration Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017. SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting To me his/her Residence Certificate No. __________________ issued at __

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    PRC Cases Templateeeeee

    Uploaded by

    Winter Kim
    37 views15 pages
    _____________________________ NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of suturing of perineal lacerations before signing the form. 2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on Suturing of Perineal Laceration Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017. SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting To me his/her Residence Certificate No. __________________ issued at __

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    PRC-Cases-Templateeeeee

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    _____________________________ NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of suturing of perineal lacerations before signing the form. 2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on Suturing of Perineal Laceration Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017. SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting To me his/her Residence Certificate No. __________________ issued at __

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    37 views15 pages

    PRC Cases Templateeeeee

    Uploaded by

    Winter Kim
    _____________________________ NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of suturing of perineal lacerations before signing the form. 2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on Suturing of Perineal Laceration Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017. SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting To me his/her Residence Certificate No. __________________ issued at __

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 15

    PROFESSIONAL REGULATION COMMISSION

    RECORD OF ACTUAL DELIVERIES HANDLED

    Please Check:

    Graduate Midwife Registered Nurse

    NAME: ______________________________________________________ SCHOOL: ________________________________

    Full Name & Check Supervised By:


    Case Complete Diagnosis Date & Time
    Name & Address of Patient Address Of Facility if Home Print Name Position/ License No./
    No. (Gravida_Para_) Performed Signature
    & Contact No. Del. & Contact No. Designation Exp. Date
    NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of internal examinations before signing the form.
    2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on the
    Expanded Functions of Midwife (R.A. 7392) Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017.

    SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting


    To me his/her Residence Certificate No. __________________ issued at ______________________on ________________________.

    CERTIFIED CORRECT:
    Signature: _ _____ Date: __ __________
    _________________________________________________ Printed Name: CHRISTOPHER R. BAÑEZ, PhD, DNM, MSN, RM, RN, LPT
    Administering Officer or Notary Public Designation: Dean
    Lic. No_0145941 Expiry Date: May 23, 2023

    AFFIX
    Documentary Stamp
    (to be posted on the last page)
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF CONDUCTED INTERNAL EXAMINATION BEFORE DELIVERY

    Please Check:

    Graduate Midwife Registered Nurse

    NAME: ______________________________________________________ SCHOOL: ________________________________

    Full Name & Check Supervised By:


    Case Complete Diagnosis Date & Time
    Name & Address of Patient Address Of Facility if Home Print Name Position/ License No./
    No. (Gravida_Para_) Performed Signature
    & Contact No. Del. & Contact No. Designation Exp. Date
    NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of internal examinations before signing the form.
    2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on the
    Expanded Functions of Midwife (R.A. 7392) Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017.

    SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting


    To me his/her Residence Certificate No. __________________ issued at ______________________on ________________________.

    CERTIFIED CORRECT:
    Signature: _ _____ Date: __ __________
    _________________________________________________ Printed Name: CHRISTOPHER R. BAÑEZ, PhD, DNM, MSN, RM, RN, LPT
    Administering Officer or Notary Public Designation: Dean
    Lic. No_0145941 Expiry Date: May 23, 2023

    AFFIX
    Documentary Stamp
    (to be posted on the last page)
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF ACTUAL INTRAVENOUS FLUID INSERTION

    Please Check:

    Graduate Midwife Registered Nurse

    NAME: ______________________________________________________ SCHOOL: ________________________________

    Full Name & Check Supervised By:


    Case Complete Diagnosis Date & Time
    Name & Address of Patient Address Of Facility if Home Print Name Position/ License No./
    No. (Gravida_Para_) Performed Signature
    & Contact No. Del. & Contact No. Designation Exp. Date
    NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of internal examinations before signing the form.
    2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on
    Intravenous Fluid Insertion Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017.

    SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting


    To me his/her Residence Certificate No. __________________ issued at ______________________on ________________________.

    CERTIFIED CORRECT:
    Signature: _ _____ Date: __ __________
    _________________________________________________ Printed Name: CHRISTOPHER R. BAÑEZ, PhD, DNM, MSN, RM, RN, LPT
    Administering Officer or Notary Public Designation: Dean
    Lic. No_0145941 Expiry Date: May 23, 2023

    AFFIX
    Documentary Stamp
    (to be posted on the last page)
    PROFESSIONAL REGULATION COMMISSION

    RECORD OF ACTUAL SUTURING OF PERINEAL LACERATION

    Please Check:

    Graduate Midwife Registered Nurse

    NAME: ______________________________________________________ SCHOOL: ________________________________

    Full Name & Check Supervised By:


    Case Complete Diagnosis Date & Time
    Name & Address of Patient Address Of Facility if Home Print Name Position/ License No./
    No. (Gravida_Para_) Performed Signature
    & Contact No. Del. & Contact No. Designation Exp. Date
    NOTE: 1) The Clinical Instructor should ensure the competence of the students in the performance of internal examinations before signing the form.
    2) Registered Midwives/Clinical Instructor who supervise Student Graduate Midwives, Registered Nurses and affix their signature in this Forsm must present Certificate of Training on the
    Expanded Functions of Midwife (R.A. 7392) Pursuant to Board Resolutions No. 100, Series of 2017, dated September 8, 2017.

    SUBSCRIBED AND SWORN TO before me this ________________ _____________at ______________________________Affiant exhibiting


    To me his/her Residence Certificate No. __________________ issued at ______________________on ________________________.

    CERTIFIED CORRECT:
    Signature: _ _____ Date: __ __________
    _________________________________________________ Printed Name: CHRISTOPHER R. BAÑEZ, PhD, DNM, MSN, RM, RN, LPT
    Administering Officer or Notary Public Designation: Dean
    Lic. No_0145941 Expiry Date: May 23, 2023

    AFFIX
    Documentary Stamp
    (to be posted on the last page)

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