ODC Form 3

DR ASSIST
FORM

Republic of the Philippines

AMANDO COPE COLLEGE
COLLEGE OF NURSING
Baranghawon, Tabaco City
Telephone Nos. (052) 830-2770 / 487-4454
CHED Recognition No. 316-2007
ASSISTED DELIVERY in DR. AMANDO D. COPE MEMORIAL HOSPITAL, Tabaco City
Hospital/Home, Lying-in Clinic, Municipality/City Province
Prepared by:
Printed Name with Signature of Student:
Patients INITIALS
(only)
Date Performed and
Time Started

Noted by:

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

SURGICAL PROCEDURE
PERFORMED

VILMA U. BORLAGDAN, RN
(Printed Name and Signature)
Clinical Coordinator, PRC I.D. No. 0083327 Valid Until:
Date document is signed: _________________ Time: ____________
Please specify Highest Nursing Degree Earned: MAN

Approved by:

D.R. Nurse /
Midwife On Duty
(Name Only)

SUPERVISED BY
Clinical Instructor
Name and Signature

MARIA RENEE O. COPE, RN

(Printed Name and Signature)
Dean, PRC I.D. No. 0090644
Valid Until:
Date document is signed: _________________ Time: ___________
Please specify Highest Nursing Degree Earned: MAN, PhD