St.

Scholasticas College Tacloban

Brgy. Campetic, Maharlika Highway, Palo, Leyte
COLLEGE OF NURSING
Email Address: ssctcn@yahoo.com

CIRCULATING NURSE in DIVINE WORD HOSPITAL, TACLOBAN CITY

Hospital, Municipality/ City/ Province O.R. FORM 1A
Prepared by: MAJOR SURGERY
Printed Name with Signature of Student: TAYABAS, JASPER KEITH Q.
PATIENTS NURSE ON DUTY
SUPERVISED BY
DATE INITIAL (Name and Signature)
SURGICAL PROCEDURE PERFORMED CLINICAL INSTRUCTOR
PERFORMED CASE If Midwife on Duty,
(Name and Signature)
NUMBER Signature not Required
CESAREAN SECTION REPEAT, LOW TRANSVERSE
January 24, G.A. PFANNENSTIEL INCISION Ms. Michelle Ann V. MRS. WILMA M. RUIZ RN, MAN
2017 56062 (Pregnancy Uterine Full Term, Not in Labor, Previous Cesarean Bacierra, RN PRC No.:0252934 Valid Until: 08-28-19
Section) PNA No.: _______ Valid Until: _______

OPEN REDUCTION INTERNAL FIXATION OF MRS. ZUSIE ABUDA RN, MAN

O.M. Ms. Monnick D. Elnas,
March 1, 2017 ZYGOMATICOMAXILLARY BONE PRC No.: 0194172 Valid Until: 01-02-19
250473 RN
(Zygomaticomaxillary Bone Complex Fracture) PNA No.: _______ Valid Until: _______

EXPLORATORY LAPAROTOMY, REMOVAL OF MRS. ZUSIE ABUDA RN, MAN

S.A. Mr. Francis Jamil S.
March 1, 2017 ABDOMINAL PACKING PRC No.: 0194172 Valid Until: 01-02-19
250317 Ocado, RN PNA No.: _______ Valid Until: _______
(Uterine Malignancy Stage IV)

MRS. WILMA M. RUIZ RN, MAN MRS. CAROLINA D. BARROT, RN, MAN, Ph.D.
Over All Clinical Coordinator DEAN, COLLEGE OF NURSING
PRC No.: 0252934 Valid Until: 08-28-19__ PRC No.: 0133674 Valid Until: 09-21-17
PNA No.: ______ Valid Until: _________ PNA No.: ______ Valid Until: __________
ADPCN: ______ Valid Until: __________
I declare under oath that these cases have been accomplished by me in good faith, verified by me and to the best of my knowledge and belief is true, correct, and complete
statement pursuant to the provisions of pertinent laws, rules, and regulations of the Republic of the Philippines.
Subscribed and sworn before me this _____________________ of _____________________ 2017, Tacloban City, Philippines.
Doc No. __________
Page No. _________
Book No. _________
Series of 2017