MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: Gregorio T. Lluch Memorial Hospital, Iligan City, Lanaodel Norte
Hospital/Home/Lying-in, Municipality/City/Province

ODC Form 1A
ACTUAL DELIVERY
FORM

Prepared by:
Printed Name and Signature of Student: SHARMAINE KATE MANON-OG JAVIER

Date Performed
and
Time Started

Patients INITIALS (only)

Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)

PROCEDURE PERFORMED

January 31, 2011

4:00 PM

L.P
09-73-70

Normal Spontaneous Vaginal Delivery

February 02, 2011

5:14 PM

A.J
09-76-65

Normal Spontaneous Vaginal Delivery

K.J.G
09-73-87

Normal Spontaneous Vaginal Delivery

February 02, 2011

7:50 PM

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________

(NSVD)

(NSVD)

(NSVD)

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty, Signature
Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Era Claire Laurel, RN

PRC Number: 0353030
Valid Until:

Ashley Ali-Bangcola, RN
PRC Number:
Valid Until:

Elene Bambi Sade, RN

PRC Number: 0584335
Valid Until:

Ashley Ali-Bangcola, RN
PRC Number:
Valid Until:

Elene Bambi Sade, RN

PRC Number: 0584335
Valid Until:

Ashley Ali-Bangcola, RN
PRC Number:
Valid Until:

Valid Until: March 17, 2016

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Time: __________________

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned:

Arts in Nursing_____

_______________________

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
SURGICAL SCRUB in: AmaiPakpak Medical Center, Marawi City, Lanaodel Sur
Hospital/Home/Lying-in, Municipality/City/ Province

ODC Form 2A
O.R. SCRUB FORM
Major

Prepared by:
Printed Name and Signature of Student: SHARMAINE KATE MANON-OG JAVIER

Date Performed
and
Time Started

October 2, 2011
12:32 AM

Patients INITIALS (only)

Case Number

M.M
11-02-08

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse on Duty

(Name and Signature)

Eva Marie Gumisad, RN

Transabdominal Hysterectomy

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364 Valid Until: March 17, 2016
September 21, 2015
Date document is signed: _______________ Time: __________________
_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____

PRC Number: 0292410

Valid Until: June 15, 2015

SUPERVISED BY
Clinical Instructor
Name and Signature
Naima D. Mala, RN, MAN
PRC Number: 0348709
Valid Until: September 03, 2015

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
SURGICAL SCRUB in: Gregorio T. Lluch Memorial Hospital, Iligan City, Lanaodel Norte
Hospital/Home/Lying-in, Municipality/City/ Province

ODC Form 2A
O.R. SCRUB FORM
Major

Prepared by:
Printed Name and Signature of Student: SHARMAINE KATE MANON-OG JAVIER

Date Performed
and
Time Started

January 10, 2013

2:28 PM

Patients INITIALS (only)

Case Number

S.D
16-27-41

SURGICAL PROCEDURE
PERFORMED

Primary Low Segment Cesarian

Section, Right Oophorectomy under
Spinal Anesthesia

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364 Valid Until: March 17, 2016
September 21, 2015
Date document is signed: _______________ Time: __________________
_____________________
Please specify highest Nursing Degree Earned:
_______________________
Arts in Nursing_____

O.R. Nurse on Duty

(Name and Signature)

Rose Ann B. Sullano, RN

PRC Number: 0584333
Valid Until:

SUPERVISED BY
Clinical Instructor
Name and Signature
ROMANOFF RAKI-IN, RN
PRC Number: 0355364
Valid Until: March 17, 2016

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:
Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: Gregorio T. Lluch Memorial Hospital, Iligan City, Lanaodel Norte
Hospital/Home/Lying-in, Municipality/City/Province

ODC Form 1C
CORD CARE FORM

Prepared by:
Printed Name and Signature of Student: SHARMAINE KATE MANON-OG JAVIER
Patients INITIALS (only)
Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)

Immediate Newborn Cord Care

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

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty, Signature
Not Required)

February 01, 2011

11:01 PM

Baby Boy Z.
03-38-70

Cord Care
Neonatal Intensive Care Unit (NICU)

Tiara Marie Leopoldo, RN

PRC Number: 0582801
Valid Until:

Ashey Ali-Bangcola, RN
PRC Number:
Valid Until:

February 03, 2011

7:16 PM

Baby Boy C.
03-93-11

Cord Care
Neonatal Intensive Care Unit (NICU)

Charity Jane Pacero, RN

PRC Number:
Valid Until:

Ashley Ali-Bangcola, RN
PRC Number:
Valid Until:

Date Performed
and
Time Started

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________

SUPERVISED BY
Clinical Instructor
Name and Signature

Valid Until: March 17, 2016

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Time: __________________

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned:

Arts in Nursing_____

_______________________

Please specify highest Nursing Degree Earned: Master of

MINDANAO STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

MARAWI CITY
www.msumain.edu.ph
(Level II AACCUP 2002)
ACTUAL DELIVERY in: AmaiPakpak Medical Center, Marawi City, Lanaodel Sur
Hospital/Home/Lying-in, Municipality/City/Province

ODC Form 1C
CORD CARE FORM

Prepared by:
Printed Name and Signature of Student: SHARMAINE KATE MANON-OG JAVIER

Date Performed
and
Time Started

January 16, 2013

2:25 PM

Patients INITIALS (only)

Case Number
(not applicable for
Birthing/Lying-in Clinics/Homes)

Immediate Newborn Cord Care

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

D.R. Nurse on Duty

(Name and Signature)
(If Midwife on Duty, Signature
Not Required)

Baby Girl G.
14-16-88

Cord Care
Neonatal Intensive Care Unit (NICU)

Maria Elena C. Puno, RN

PRC Number: 0427163
Valid Until:

Noted by: ROMANOFF RAKI-IN, RN

(Print Name and Signature)
Clinical Coordinator, PRC I.D. No.: 0355364
September 21, 2015
Date document is signed: _______________
_____________________

SUPERVISED BY
Clinical Instructor
Name and Signature
Ma. Theresa G. Namalata, RN
PRC Number:
Valid Until:

Valid Until: March 17, 2016

Approved by: NUR-HANNIPHA B. DERICO, RN, RM, MAN, Ph. D

(Print Name and Signature)
Dean, PRC I.D. No.: 0074194____________
Valid Until:

Time: __________________

Date document is signed: ______________

Time:

Please specify highest Nursing Degree Earned:

Arts in Nursing_____

_______________________

Please specify highest Nursing Degree Earned: Master of