PAMANTASAN NG LUNGSOD NG MAYNILA

(UNIVERSITY OF THE CITY OF MANILA) O.R. Form 1A

General Luna corner Muralla Sts., Manila, Philippines, 1002 O.R. SCRUB FORM
Telephone No. (+632) 643 2500
MAJOR
Web Address: www.plm.edu.ph

SURGICAL SCRUB in OSPITAL NG MAYNILA MEMORIAL CENTER, MANILA

Hospital, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student (SURNAME, FIRST NAME, MIDDLE NAME)

Patient's INITIALS (only)

Date Performed SUPERVISED BY
O.R Nurse On Duty
and SURGICAL PROCEDURE PERFORMED Clinical Instructor
(Name and Signature)
Time Started (Name and Signature)
Case Number

OCTOBER 20, 2016 LBA

EXPLORATORY LAPAROTOMY
9:00 AM 9865733-11 JUAN A. DELA CRUZ, RN LENIE O. CRUZ, R.N, MAN

Noted by: DAVID PAUL R. RAMOS, RN, MAN Approved by: MA. CECILIA O. MARTINEZ, Ed.D
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. 0387818 Valid Until 07/06/2021 Dean, PRC I.D. No. 0218121 Valid Until 3/15/2021
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA) O.R. Form 1B
General Luna corner Muralla Sts., Manila, Philippines, 1002 O.R. CIRCULATING
Telephone No. (+632) 643 2500
FORM
Web Address: www.plm.edu.ph

SURGICAL SCRUB in
Hospital, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student

Patient's INITIALS (only)

Date Performed SUPERVISED BY
O.R Nurse On Duty
and SURGICAL PROCEDURE PERFORMED Clinical Instructor
(Name and Signature)
Time Started (Name and Signature)
Case Number

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until

Date document is signed: Time Date document is signed: Time

Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA) D.R. Form
General Luna corner Muralla Sts., Manila, Philippines, 1002 ACTUAL DELIVERY
Telephone No. (+632) 643 2500
FORM
Web Address: www.plm.edu.ph

ACTUAL DELIVERY in
Hospital/Home/Lying-in Clinic, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student

Patient's INITIALS (only) D.R. Nurse On Duty

Date Performed SUPERVISED BY
(Name and Signature)
and PROCEDURE PERFORMED Clinical Instructor
Case Number (If Midwife on Duty,
Time Started (Name and Signature)
(not applicable for Birthing/Lying- Signature Not Required)
In Clinics/Homes)

GRAVIDA 3 PARA 2
OCTOBER 25, 2019 LAP PREGNANCY IN UTERINE FULL TERM
9:00 AM 684995 40 WEEKS AGE OF GESTATION ROBERTO R. MANUEL, RN JUAN DELA CRUZ, RN, MAN
CEPHALIC IN LABOR

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING
 PAMANTASAN NG LUNGSOD NG MAYNILA
(UNIVERSITY OF THE CITY OF MANILA)
General Luna corner Muralla Sts., Manila, Philippines, 1002
Telephone No. (+632) 643 2500 ICNB Form
Web Address: www.plm.edu.ph IMMEDIATE CARE OF THE
NEWBORN FORM

IMMEDIATE NEWBORN CORD CARE in

Hospital/Home/Lying-in Clinic, Municipality/City/ Province

Prepared by:
Printed Name with Signature of Student

Patient's INITIALS (only) IMMEDIATE NEWBORN CORD CARE D.R. Nurse On Duty
Date Performed PERFORMED SUPERVISED BY
(Name and Signature)
and Clinical Instructor
Case Number (If Midwife on Duty,
Time Started Indicate where performed e.g. D.R., Nursery, NICU, or (Name and Signature)
(not applicable for Birthing/Lying- Home Signature Not Required)
In Clinics/Homes)

OCTOBER 25, 2019

9:00 AM ABS 5156698 DELIVERY ROOM MARIA ANA MARQUEZ, RN DENZEL M. WASHINGTON, RN, MAN

Noted by: Approved by:

(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No. Valid Until Dean, PRC I.D. No. Valid Until

Date document is signed: Time Date document is signed: Time

Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING Please specify Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING