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    Universidad de Zamboanga: Don Toribio ST., Tetuan, Zamboanga City Philippines

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    Raf Aylani
    This document contains several forms from the University of Zamboanga documenting nursing students' supervised clinical experiences, including assisted deliveries, newborn care, surgical scrubbing and minor procedures. The forms provide identifying information about patients and procedures, and are signed by the students, supervising nurses and clinical coordinators/dean to verify the students' participation.

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

    Universidad de Zamboanga: Don Toribio ST., Tetuan, Zamboanga City Philippines

    Uploaded by

    Raf Aylani
    79 views6 pages
    This document contains several forms from the University of Zamboanga documenting nursing students' supervised clinical experiences, including assisted deliveries, newborn care, surgical scrubbing and minor procedures. The forms provide identifying information about patients and procedures, and are signed by the students, supervising nurses and clinical coordinators/dean to verify the students' participation.

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    This document contains several forms from the University of Zamboanga documenting nursing students' supervised clinical experiences, including assisted deliveries, newborn care, surgical scrubbing and minor procedures. The forms provide identifying information about patients and procedures, and are signed by the students, supervising nurses and clinical coordinators/dean to verify the students' participation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    79 views6 pages

    Universidad de Zamboanga: Don Toribio ST., Tetuan, Zamboanga City Philippines

    Uploaded by

    Raf Aylani
    This document contains several forms from the University of Zamboanga documenting nursing students' supervised clinical experiences, including assisted deliveries, newborn care, surgical scrubbing and minor procedures. The forms provide identifying information about patients and procedures, and are signed by the students, supervising nurses and clinical coordinators/dean to verify the students' participation.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    U IV R ID DD Z M O N A N ES A E A B A G

    Don Toribio St., Tetuan, Zamboanga City, Philippines


    Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

    ODC Form 1B
    ASSISTED DELIVERY FORM

    Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 ASSISTED DELIVERY in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

    Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari
    Date Performed and Time Started Patients INITIALS (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 is not Required)

    SUPERVISED BY: Clinical Instructor Name and Signature

    May 10,2011 7:58 am

    C.M 421654

    Normal Spontaneous Vaginal Delivery Aimee Apolinario,RN Madeleine Ruth FelicesAlmonte,RM,RN

    Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
    PNA I.D. No.______ Date document is signed: Time: Please specify Highest Nursing Degree Earned:

    January 24, 2012 Valid Until: ______________ Master in Nursing

    Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
    PNA I.D. No._______ Valid Until: _____________________ Date document is signed: Time: Specify Highest Nursing Degree Earned: Master in Nursing

    U IV R ID DD Z M O N A N ES A E A B A G
    Don Toribio St., Tetuan, Zamboanga City, Philippines

    ODC Form 1B
    ASSISTED DELIVERY FORM

    Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

    Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 ASSISTED DELIVERY in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

    Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari
    Date Performed and Time Started Patients INITIALS (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 is not Required)

    SUPERVISED BY: Clinical Instructor Name and Signature

    May 10, 2011 1:45 pm

    C.M 422747

    Normal Spontaneous Vaginal Delivery Aimee Apolinario,RN Madeleine Ruth Felices Almonte,RM,RN

    Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
    PNA I.D. No.________ Date document is signed: Time: Please specify Highest Nursing Degree Earned:

    Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976
    Valid Until: March 13, 2012 PNA I.D. No. _______ Valid Until: _____________________ Date document is signed: Time: ________ Specify Highest Nursing Degree Earned: Master in Nursing

    January 24, 2012___ Valid Until: ___________________ _______ Master in Nursing_____________

    U IV R ID DD Z M O N A N ES A E A B A G

    ODC Form 1C
    CORD CARE FORM

    Don Toribio St., Tetuan, Zamboanga City, Philippines


    Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

    Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 IMMEDIATE NEWBORN CORD CAREin Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

    Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari
    Date Performed and Time Started Patients INITIALS (only) Case Number

    PROCEDURE PERFORMED

    D.R. Nurse On Duty (Name and Signature)

    SUPERVISED BY: Clinical Instructor Name and Signature

    May 11,2011 9:25 am

    C.S 423304

    Immediate Newborn Cord Care

    Luzviminda Rugayan,RN,RM

    Madeleine Ruth Felices Almonte,RM,RN

    Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
    PNA I.D. No._______ Date document is signed: ____ Please specify Highest Nursing Degree Earned:

    January 24, 2012 Valid Until: ____________________ Time: _______ Master in Nursing

    Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
    PNA I.D. No. _______ Valid Until: ___________ _ Date document is signed: Time: ____ Specify Highest Nursing Degree Earned: Master in Nursing

    U IV R ID DD Z M O N A N ES A E A B A G
    Don Toribio St., Tetuan, Zamboanga City, Philippines

    ODC Form 2A
    D.R. SCRUB FORM Minor

    Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

    Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

    Prepared by: Printed Name with Signature of Student: Malali, Nurhaina Atari

    Date Performed and Time Started

    Patients INITIALS Case Number

    SURGICAL PROCEDURE PERFORMED

    O.R. Nurse On Duty

    SUPERVISED BY: Clinical Instructor

    May 10,2011 10:15 am

    E.T 420976

    Episiorraphy

    Aimee Apolinario,RN

    Madeleine Ruth Felices Almonte,RM,RN

    Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
    PNA I.D. No._____ Date document is signed: Time: Please specify Highest Nursing Degree Earned:

    January 24, 2012 Valid Until: ___________________ _______ Master in Nursing

    Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
    PNA I.D. No. ____________ Valid Until: ____________________ Date document is signed: Time: Specify Highest Nursing Degree Earned: Master in Nursing

    U IV R ID DD Z M O N A N ES A E A B A G
    Don Toribio St., Tetuan, Zamboanga City, Philippines
    Telephone No.(062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

    ODC Form 1A
    ACTUAL DELIVERY FORM

    Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 ACTUAL DELIVERY in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

    Prepared by: Printed Name with Signature of Student: Misa, Ahmad Edfar Tiamwat
    Date Performed and Time Started Patients INITIALS (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 is not Required)

    SUPERVISED BY: Clinical Instructor Name and Signature

    May 12,2011 7:06 am

    L .S .A 435 245

    Normal Spontaneous Vaginal Delivery Amor Angelie B. Bazan, RM Ethel Usman,RN,RM

    Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator,PRC I.D. No. 0311858 Valid Until:
    PNA I.D. No._______

    January 24, 2012 Valid Until:_____________________ Date document is signed: Time: Please specify Highest Nursing Degree Earned: Master in Nursing

    Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean,PRC I.D. No. 0205976 Valid Until: March 13, 2012
    PNA I.D. No. _______ Valid Until:____________ Date document is signed: Time: ________ Specify Highest Nursing Degree Earned: Master in Nursing

    U IV R ID DD Z M O N A N ES A E A B A G
    Don Toribio St., Tetuan, Zamboanga City, Philippines
    Telephone No. (062) 990-1849 / Fax No. (062) 991-3094 / Web-Site: www.uz.edu.ph

    ODC Form 2B
    O.R. SCRUB FORM Minor

    Accredited by: ISO 9001:2000 Certified/CIP/3310/05/03/410 / April 15, 2005 SURGICAL SCRUB in Zamboanga City Medical Center, Zamboanga City Hospital, Municipality / City / Province

    Prepared by: Printed Name with Signature of Student: ESMAEL, TASNEEM APOSTOL

    Date Performed and Time Started

    Patients INITIALS Case Number

    SURGICAL PROCEDURE PERFORMED

    O.R. Nurse On Duty

    SUPERVISED BY: Clinical Instructor

    Noted by: REYNITA BIONG-SAGUBAN, R.N., M.N. Clinical Coordinator, PRC I.D. No. 0311858 Valid Until:
    PNA I.D. No. 017601 Date document is signed: Please specify Highest Nursing Degree Earned:

    January 24, 2012 Valid Until: October 31, 2010 Time: Master in Nursing

    Approved by: VIVIAN C. LAPUT, R.N., M.N. Dean, PRC I.D. No. 0205976 Valid Until: March 13, 2012
    PNA I.D. No. 017607 Valid Until: October 31, 2010 Date document is signed: Time: Specify Highest Nursing Degree Earned: Master in Nursing

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