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Arellano University: Jose Abad Santos Campus

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Lloyd Vargas

The document appears to be forms from Arellano University related to clinical procedures performed by nursing students. It includes several forms for documenting actual deliveries, assisted deliveries, newborn cord care, surgical scrubs, and circulating. The forms require information such as the location of the procedure, the student's name, date, patient initials, case number, procedure performed, supervising staff, and approvals from the Dean and Clinical Coordinator.

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Arellano University: Jose Abad Santos Campus

Uploaded by

Lloyd Vargas
142 views7 pages
The document appears to be forms from Arellano University related to clinical procedures performed by nursing students. It includes several forms for documenting actual deliveries, assisted deliveries, newborn cord care, surgical scrubs, and circulating. The forms require information such as the location of the procedure, the student's name, date, patient initials, case number, procedure performed, supervising staff, and approvals from the Dean and Clinical Coordinator.

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Cases

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The document appears to be forms from Arellano University related to clinical procedures performed by nursing students. It includes several forms for documenting actual deliveries, assisted deliveries, newborn cord care, surgical scrubs, and circulating. The forms require information such as the location of the procedure, the student's name, date, patient initials, case number, procedure performed, supervising staff, and approvals from the Dean and Clinical Coordinator.

Copyright:

Attribution Non-Commercial (BY-NC)
Download as DOC, PDF, TXT or read online from Scribd
Download as doc, pdf, or txt
142 views7 pages

Arellano University: Jose Abad Santos Campus

Uploaded by

Lloyd Vargas
The document appears to be forms from Arellano University related to clinical procedures performed by nursing students. It includes several forms for documenting actual deliveries, assisted deliveries, newborn cord care, surgical scrubs, and circulating. The forms require information such as the location of the procedure, the student's name, date, patient initials, case number, procedure performed, supervising staff, and approvals from the Dean and Clinical Coordinator.

Copyright:

Attribution Non-Commercial (BY-NC)
Download as DOC, PDF, TXT or read online from Scribd
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ARELLANO UNIVERSITY

Jose Abad Santos Campus


3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116 Telefax:833-4728

ODC Form 1A Actual Delivery Form

ACTUAL DELIVERY in__Mission HospitaL/ Mary Johnson HospitaL/ Lanuza Lying-in Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed name and Signature of Student__ Realyn M. Braa_________________________________________ Date performed and Time Started Patients INITIAL Only
Case Number (not applicable for birthing/ Lying-In Clinics/Homes)

PROCEDURE PERFORMED

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

9/ 23/10( 5:52 pm) 4/15/11 ( 1:45pm) 5/5/11 12/6/11( 6:43am) 12/13/11 (5:41am)

200738 322869 069694 955278 95603

NSD NSD NSD NSD NSD

Kristina Pruna

Noted by: ___________________________________ (Print Name and Signature)


Clinical Coordinator, PRC I.D No. _______ Valid Until_______ Date document is signed:________________ Time___________ Please specify Highest Nursing Degree Earned:______________

Approved by: ____________________________________


(Print Name and Signature)

Dean, PRC I.D No. __________________ Valid Until_____________ Date document is signed:________________ Time________________ Please specify Highest Nursing Degree Earned:___________________ (STRICTLY NO DESIGNATES)

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116 Telefax:833-4728

ODC Form 1B Assisted Delivery Form

ACTUAL DELIVERY in_______________________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed name and Signature of Student______________________________________________ Date performed and Time Started Patients INITIAL Only
Case Number (not applicable for birthing/ Lying-In Clinics/Homes)

PROCEDURE PERFORMED
ASSISTED DELIVERY

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ___________________________________ (Print Name and Signature)


Clinical Coordinator, PRC I.D No. _______ Valid Until_______ Date document is signed:________________ Time___________ Please specify Highest Nursing Degree Earned:______________

Approved by: ____________________________________


(Print Name and Signature)

Dean, PRC I.D No. __________________ Valid Until_____________ Date document is signed:________________ Time________________ Please specify Highest Nursing Degree Earned:___________________ (STRICTLY NO DESIGNATES)

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116 Telefax:833-4728

ODC Form 1C Cord Care Form

IMMEDIATE NEWBORN CORD CARE in__Metro Rizal Doctors/Ospital ng Maynila/ Bernardino Hospital Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed name and Signature of Student___Realyn M. Braa Date performed and Time Started Patients INITIAL Only
Case Number (not applicable for birthing/ Lying-In Clinics/Homes)

Immediate Newborn Cord Care PERFORMED


(Indicate where performed e.g. DR, Nursery, NICU, or Home)

Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

7/12/10 8/16/11 8/17/11 5/4/11 5/4/11

0999517 670745 670751 076192 075468

NICU NICU NIUC NICU NICU

Ruisa Nilo Ruisa Nilo

Noted by: ___________________________________ (Print Name and Signature)


Clinical Coordinator, PRC I.D No. _______ Valid Until_______ Date document is signed:________________ Time___________ Please specify Highest Nursing Degree Earned:______________

Approved by: ____________________________________


(Print Name and Signature)

Dean, PRC I.D No. __________________ Valid Until_____________ Date document is signed:________________ Time________________ Please specify Highest Nursing Degree Earned:___________________ (STRICTLY NO DESIGNATES)

ARELLANO UNIVERSITY
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116 Telefax:833-4728

Jose Abad Santos Campus

ACTUAL DELIVERY in_______________________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed name and Signature of Student______________________________________________ Date performed and Time Started Patients INITIAL Only
Case Number (not applicable for birthing/ Lying-In Clinics/Homes)

D.R. Form ACTUAL DELIVERY FORM

PROCEDURE PERFORMED

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

IMMEDIATE NEWBORN CORD CARE in_______________________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province Prepared by: Printed name and Signature of Student______________________________________________ Date performed and Time Started Patients INITIAL Only
Case Number (not applicable for birthing/ Lying-In Clinics/Homes)

ICNB Form Immediate Care ofr the Newborn Form

Immediate Newborn Cord Care PERFORMED


(Indicate where performed e.g. DR, Nursery, NICU, or Home)

Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not Required)

SUPERVISED BY Clinical Instructor Name and Signature

(STRICTLY NO DESIGNATES) (These Forms must be printed at the back of the 1st page of the Competency-based performance Evaluation Checklist)

ARELLANO UNIVERSITY
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116 Telefax:833-4728

Jose Abad Santos Campus

SURGICAL SCRUB in____Mission Hospital/ Alabang Medical Center Hospital/ Municipality/City/Province Prepared by: Printed name and Signature of Student__Realyn M. Braa Date performed and Time Started Patients INITIAL Only
Case Number

O.R Form 1A
O.R Scrub Form Major

SURGICAL PROCEDURE PERFORMED

O.R Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

9/23/10 4/25/11

20743 1113630

Appendectomy Laparoscopic Cholesistectomy

Kristine Pruna Ana mae Guitoria

Prepared by: Printed name and Signature of Student___Devine Medical Center/ Alabang Medical Center Date performed and Time Started Patients INITIAL Only
Case Number

O.R Form 1B
O.R Circulating Form

SURGICAL PROCEDURE PERFORMED

O.R Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

7/18/11

11072175

Debridment and revision of middle finger

Dr. Virginia A. Perey

2/7/11

1113597

Stat Appendectomy
(STRICTLY NO DESIGNATES)

Ana mae Guitoria

(These Forms must be printed at the back of the 1st page of the Competency-based performance Evaluation Checklist)

ARELLANO UNIVERSITY
Jose Abad Santos Campus
3058 Taft Avenue, Pasay City, Philippines 1300
Tel Nos: 832-2446; 832-5525; 831-8077 Loc 101-116 Telefax:833-4728

ODC Form 2B Cord Care Form

SURGICAL SCRUB in_______________________________________________________________________________________ Hospital Municipality/City/Province Prepared by: Printed name and Signature of Student______________________________________________ Date performed and Time Started Patients INITIAL Only
Case Number

SURGICAL PROCEDURE PERFORMED

O.R Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: ___________________________________ (Print Name and Signature)


Clinical Coordinator, PRC I.D No. _______ Valid Until_______ Date document is signed:________________ Time___________ Please specify Highest Nursing Degree Earned:______________

Approved by: ____________________________________


(Print Name and Signature)

Dean, PRC I.D No. __________________ Valid Until_____________ Date document is signed:________________ Time________________ Please specify Highest Nursing Degree Earned:___________________

(STRICTLY NO DESIGNATES)

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