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visiRepublic of the Philippines Bicol University COLLEGE OF NURSING Legazpi City AACCUP LEVEL III (2009) and ISO

9001-2008 Accredited (2010) SURGICAL SCRUB in _________________________________________________ Hospital, Municipality/ City/ Province Prepared by: Printed Name with Signature of Student: ____________________________________ Date Performed and Time Started Patients INITIALS (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name and Signature)

ODC Form 2A O.R. SCRUB Form

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:

Republic of the Philippines Bicol University COLLEGE OF NURSING Legazpi City AACCUP LEVEL III (2009) and ISO 9001-2008 Accredited (2010) SURGICAL SCRUB in _________________________________________________ Hospital, Municipality/ City/ Province Prepared by: Printed Name with Signature of Student: ____________________________________ Date Performed and Time Started Patients INITIALS (only) Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse On Duty (Name and Signature)

ODC Form 2B O.R. CIRCULATING Form

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:

Republic of the Philippines Bicol University COLLEGE OF NURSING Legazpi City AACCUP LEVEL III (2009) and ISO 9001-2008 Accredited (2010) ACTUAL DELIVERY in _________________________________________________ Hospital, Municipality/ City/ Province Prepared by: Printed Name with Signature of Student: ____________________________________ Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing/LyingIn Clinic/Homes)

ODC Form 1A 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

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:

Republic of the Philippines Bicol University COLLEGE OF NURSING Legazpi City AACCUP LEVEL III (2009) and ISO 9001-2008 Accredited (2010) ASSISTED DELIVERY in _________________________________________________ Hospital, Municipality/ City/ Province Prepared by: Printed Name with Signature of Student: ____________________________________ Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing/LyingIn Clinic/Homes)

ODC Form 1B Assisted 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

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:

Republic of the Philippines Bicol University COLLEGE OF NURSING Legazpi City AACCUP LEVEL III (2009) and ISO 9001-2008 Accredited (2010)

ODC Form 1C Cord Care Form

IMMEDIATE CARE OF NEWBORN in _________________________________________________ Hospital, Municipality/ City/ Province Prepared by: Printed Name with Signature of Student: ____________________________________ Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing/LyingIn Clinic/Homes)

Immediate Newborn Cord Care PERFORMED


Indicate where performed e.g. D.R., Nursery, NICU, or Home

N.I.C.U. 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:

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