SAINT MICHAEL’S COLLEGE OF LAGUNA

School of Nursing
Old National Road, Biñan, Laguna
(049) 511-9359 loc 312  Tele fax (02) 520-6749  www.smcl.edu.ph

SURGICAL SCRUB
in
Hospital, Municipality/ City/ Province
Prepared by:
Name of Signature of
Student Student

Date Patient’ s Name PROCEDURE O. R. Nurse On SUPERVISED BY

Performed
and Case Number PERFORMED Duty Clinical Instructor
Major Operation ( Name only) Name and Signature
Time Started

Noted Concurred
by: by:
Clinical Coordinator, PRC Valid Chief Nurse, PRC ID Valid Until
ID No. Until No.
Valid
PNA No. PNA No. Valid Until
Until
Date document is Date document is
Time Time
signed: signed:
Highest Nursing Degree Earned: Highest Nursing Degree Earned:
 SAINT MICHAEL’S COLLEGE OF LAGUNA
School of Nursing
Old National Road, Biñan, Laguna
(049) 511-9359 loc 312  Tele fax (02) 520-6749  www.smcl.edu.ph
Approved
by:
Dean, PRC ID Valid Until PNA No. Valid Until
No.

SURGICAL SCRUB
in
Hospital, Municipality/ City/ Province
Prepared by:
Name of Signature of
Student Student

Date Patient’ s Name PROCEDURE O. R. Nurse On SUPERVISED BY

Performed
and Case Number PERFORMED Duty Clinical Instructor
Minor Operation ( Name only) Name and Signature
Time Started

Noted Concurred
by: by:
Clinical Coordinator, PRC Valid Chief Nurse, PRC ID Valid Until
ID No. Until No.
 SAINT MICHAEL’S COLLEGE OF LAGUNA
School of Nursing
Old National Road, Biñan, Laguna
(049) 511-9359 loc 312  Tele fax (02) 520-6749  www.smcl.edu.ph
Valid
PNA No. PNA No. Valid Until
Until
Date document is Date document is
Time Time
signed: signed:
Highest Nursing Degree Earned: Highest Nursing Degree Earned:

Approved
by:
Dean, PRC ID Valid Until PNA No. Valid Until
No.

ACTUAL DELIVERY
in
Hospital, Municipality/ City/ Province
Prepared by:
Name of Signature of
Student Student

Date Patient’ s Name D. R.

PROCEDURE SUPERVISED BY
Performed Nurse/ Midwife
Case Number Clinical Instructor
and
( not applicable for Birthing/ Lying- In PERFORMED On Duty Name and Signature
Time Started Clinics/ Homes) ( Name only)
 SAINT MICHAEL’S COLLEGE OF LAGUNA
School of Nursing
Old National Road, Biñan, Laguna
(049) 511-9359 loc 312  Tele fax (02) 520-6749  www.smcl.edu.ph
Noted Concurred
by: by:
Clinical Coordinator, PRC Valid Chief Nurse, PRC ID Valid Until
ID No. Until No.
Valid
PNA No. PNA No. Valid Until
Until
Date document is Date document is
Time Time
signed: signed:
Please specify Highest Nursing Degree
Highest Nursing Degree Earned: Earned:

Approved
by:
Dean, PRC ID Valid Until PNA No. Valid Until
No.

ASSISTED DELIVERY
in
Hospital, Municipality/ City/ Province
Prepared by:
Name of Signature of
Student Student

Date Patient’ s Name D. R.

PROCEDURE SUPERVISED BY
Performed Nurse/ Midwife
Case Number Clinical Instructor
and
( not applicable for Birthing/ Lying- In PERFORMED On Duty Name and Signature
Time Started Clinics/ Homes) ( Name only)
 SAINT MICHAEL’S COLLEGE OF LAGUNA
School of Nursing
Old National Road, Biñan, Laguna
(049) 511-9359 loc 312  Tele fax (02) 520-6749  www.smcl.edu.ph

Noted Concurred
by: by:
Clinical Coordinator, PRC Valid Chief Nurse, PRC ID Valid Until
ID No. Until No.
Valid
PNA No. PNA No. Valid Until
Until
Date document is Date document is
Time Time
signed: signed:
Highest Nursing Degree Earned: Highest Nursing Degree Earned:

Approved
by:
Dean, PRC ID Valid Until PNA No. Valid Until
No.

IMMEDIATE NEWBORN CORD

CARE in
Hospital, Municipality/ City/ Province
Prepared by:
Name of Signature of
Student Student

Date Patient’ s Name D. R.

PROCEDURE SUPERVISED BY
Performed Nurse/ Midwife
Case Number Clinical Instructor
and
( not applicable for Birthing/ Lying- In PERFORMED On Duty Name and Signature
Time Started Clinics/ Homes) ( Name only)
 SAINT MICHAEL’S COLLEGE OF LAGUNA
School of Nursing
Old National Road, Biñan, Laguna
(049) 511-9359 loc 312  Tele fax (02) 520-6749  www.smcl.edu.ph

Noted Concurred
by: by:
Clinical Coordinator, PRC Valid Chief Nurse, PRC ID Valid Until
ID No. Until No.
Valid
PNA No. PNA No. Valid Until
Until
Date document is Date document is
Time Time
signed: signed:
Highest Nursing Degree Earned: Highest Nursing Degree Earned:

Approved
by:
Dean, PRC ID Valid Until PNA No. Valid Until
No.