UNIVERSITY OF BAGUIO

ODC Form 2A
School of Nursing O.R. SCRUB FORM
Upper General Luna Road, 2600 Baguio City MAJOR
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Notre Dame de Chartres Hospital, Baguio City

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)
OPERATIVE LAPAROSCOPY LEFT
DECEMBER 11, 2010 H. G. G.
SALPINGO-OOPHORECTOMY
8:18 AM 2010120117 JANE KENNETH C. TECSON, RN
ADHESIOLYSIS CHROMOTUBATION CORAZON D. INES, RN, MAN

DECEMBER 17, 2010 M.S.D. EXTRA CAPSULAR CATARACT

10:09 AM 93741B EXTRACTION WITH POSTERIOR RAYMUND . COSI, RN CORAZON D. INES, RN, MAN
CHAMBER INTRAOCULAR LENS

DECEMBER 17, 2010 M. C. A. G. PHACOEMULSIFICATION WITH

1:24 PM 2010120222 POSTERIOR CHAMBER INTRAOCULAR RAYMUND . COSI, RN CORAZON D. INES, RN, MAN
LENS, RIGHT EYE

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: __________ Time: ___________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 2A
School of Nursing O.R. SCRUB FORM
Upper General Luna Road, 2600 Baguio City MAJOR
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Notre Dame de Chartres Hospital, Baguio City

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed Patient’s INITIALS Only PROCEDURE PERFORMED O.R. Nurse On Duty SUPERVISED BY
and (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)
MAY 25, 2010 T. P. E. DIAGNOSTIC HYSTEROSCOPY,
7:40 AM 2010050334 HYSTEROSCOPIC POLYPECTOMY, MA. KATHRINA . ESPINILLA, RN LUCIA . PAYAGEN, RN, MAN
CERVICAL BIOPSY
DECEMBER 11, 2010 H. G. G. OPERATIVE LAPAROSCOPY LEFT
8:18 AM 2010120117 SALPINGO-OOPHORECTOMY JANE KENNETH C. TECSON CORAZON D. INES, RN, MAN
ADHESIOLYSIS CHROMOTUBATION
DECEMBER 17, 2010 M.S.D. EXTRA CAPSULAR CATARACT
10:09 AM 93741B EXTRACTION WITH POSTERIOR RAYMUND . COSI, RN CORAZON D. INES, RN, MAN
CHAMBER INTRAOCULAR LENS

DECEMBER 17, 2010 M. C. A. G. PHACOEMULSIFICATION WITH

1:24 PM 2010120222 POSTERIOR CHAMBER INTRAOCULAR RAYMUND . COSI, RN CORAZON D. INES, RN, MAN
LENS, RIGHT EYE

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 2A
School of Nursing O.R. SCRUB FORM
Upper General Luna Road, 2600 Baguio City MAJOR
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Tagudin General Hospital and Capillariasis Center, Tagudin, Ilocos Sur
Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

OCTOBER 01, 2010 M. P. G.

LOW CERVICAL CESAREAN SECTION JANICE . LETI, RN AILEEN DOCTOR, RN
6:11 PM 096790

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 2A
School of Nursing O.R. SCRUB FORM
Upper General Luna Road, 2600 Baguio City MAJOR
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Bethany Hospital, San Fernando, La Union

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

JANUARY 07, 2010 B. F. B. TOTAL ABDOMINAL HYSTERECTOMY

1:44 PM 06 BILATERAL SALPINGO OOPHORECTOMY DOLORES A. OLAVARIO, RN MARY JANE M. BOTIWEY, RN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 2B
School of Nursing O.R. MINOR FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Notre Dame de Chartres Hospital, Baguio City

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)
JUNE 01, 2010 CLOSED REDUCTION, NASAL BONE
W. A. A. MAUREEN LORENCE P. FUNTEBAJA LUCIA . PAYAGEN, RN, MAN
7:20 AM FRACTURE
74539B

DECEMBER 09, 2010 R. A. C. CYSTOSCOPY WITH BIOPSY RAYMUND . COSI, RN CORAZON D. INES, RN, MAN
11:49 AM 93050B

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO ODC Form 2B

O.R. MINOR FORM
 School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Lepanto Consolidated Mining Company Hospital, Lepanto, Benguet

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

FEBRUARY 10, 2011 E. S. D. WOUND EXPLORATION WITH FOREIGN

HEIDI A. MONTOYA, RN NELLIE C. PALGUE, RN
9:03 AM 11126 BODY EXTRACTION

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)

ODC Form 2B
UNIVERSITY OF BAGUIO O.R. MINOR FORM
 School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Bethany Hospital, San Fernando, La Union

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FENANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

JANUARY 14, 2011 A.L.A INCISION AND CURETTAGE OF

DOLORES A. OLAVARIO, RN MARY JANE M. BOTIWEY, RN
12:55 PM 08 CHALAZION

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO ODC Form 2B

O.R. MINOR FORM
 School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Tagudin General Hospital and Capillariasis Center, Tagudin, Ilocos Sur
Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FENANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

September 02, 2010 L. M. C.

BILATERAL TUBAL LIGATION JANICE . LETI, RN DARWIN . DIAZ, RN
1:21 pm 095887

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)

ODC Form 2B
UNIVERSITY OF BAGUIO O.R. MINOR FORM
 School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

SURGICAL SCRUB in Notre Dame de Chartres Hospital, Baguio City

Hospital, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Date Performed O.R. Nurse On Duty SUPERVISED BY

Patient’s INITIALS Only
and PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started Case Number (Name and Signature)

DECEMBER 09, 2010 R. A. C. CYSTOSCOPY WITH BIOPSY RAYMUND . COSI, RN CORAZON D. INES, RN, MAN
93050B

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO
ODC Form 1A
ACTUAL DELIVERY
 School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ACTUAL DELIVERY in Benguet General Hospital, La Trinidad, Benguet

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

AUGUST 26, 2010 M. P. B.

NORMAL SPONTANEOUS DELIVERY
12:07 PM 276084 LUZ B. KEDIAM, RN MA THERESA . MACARAEG, RN, MAN

AUGUST 27, 2010 J. M. L. NORMAL SPONTANEOUS DELIVERY

11:36 AM 276885 JENNIFER S. KIM, RN KAREN MARIE K. CHUNGALAN, RN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1A
School of Nursing ACTUAL DELIVERY
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ACTUAL DELIVERY in Lepanto Consolidated Mining Company Hospital, Lepanto, Benguet

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

February 10, 2011 G. A. M.

NORMAL SPONTANEOUS DELIVERY HEIDI A. MONTOYA, RN NELLIE C. PALGUE, RN
5:45 AM 11133

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 ODC Form 1A
UNIVERSITY OF BAGUIO ACTUAL DELIVERY
School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ACTUAL DELIVERY in Gabriela Silang General Hospital

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

MARCH 05, 2011 J. M. M.

NORMAL SPONTANEOUS DELIVERY RACQUEL . QUERUBIN, RN
1:30 AM 08009994

MARCH 06, 2011 S. R. S.

NORMAL SPONTANEOUS DELIVERY
4:16 AM 08030508 ELVIE . NAVARRO, RN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1B
School of Nursing ASSISTED DELIVERY FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ASSISTED DELIVERY in Tagudin General Hospital and Capillariasis Center, Tagudin, Ilocos Sur
Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

DECEMBER 27, 2010 I. E. R.

NORMAL SPONTANEOUS DELIVERY SONIA G. GAO-AY, RM JOEL A. VALENCIA, RN
8:05 AM 098718

DECEMBER 29, 2010 L. G. E. NORMAL SPONTANEOUS DELIVERY SONIA G. GAO-AY, RM JOEL A. VALENCIA, RN
10:11 AM 098725

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1B
School of Nursing ASSISTED DELIVERY
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ASSISTED DELIVERY in Lepanto Consolidated Mining Company Hospital, Lepanto, Benguet

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

FEBRUARY 04, 2011 N. P. C.

NORMAL SPONTANEOUS DELIVERY HEIDI A. MONTOYA, RN NELLIE C. PALGUE
3:45 PM 11103

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1B
School of Nursing ASSISTED DELIVERY FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ASSISTED DELIVERY in Benguet General Hospital, La Trinidad, Benguet

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

AUGUST 19, 2010 B. L. B.

NORMAL SPONTANEOUS DELIVERY LUZ B. KEDIAM, RN KAREN MARIE K. CHUNGALAN, RN
11:23 AM 271814

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 ODC Form 1B
UNIVERSITY OF BAGUIO ASSISTED DELIVERY
School of Nursing
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

ASSISTED DELIVERY in Gabriel Silang General Hospital, Vigan City

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed D.R. Nurse On Duty SUPERVISED BY
and Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

MARCH 04, 2011 V. T. A.

NORMAL SPONTANEOUS DELIVERY RACQUEL . QUERUBIN, RN
11:12 PM 08035479

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing

(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Pozorrubio Municipal Hospital, Pozorrubio, La Union

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

NOVEMBER 13, 2010 BABY BOY R. IMMEDIATE NEWBORN CORD CARE /

JANVIC NERRIE C. GOBOT, RN PURPLE ANN P. LABOTAN
3:59 AM 062047 DELIVERY ROOM

NOVEMBER 20, 2010 BABY GIRL G. IMMEDIATE NEWBORN CORD CARE /

062319 DELIVERY ROOM MELANIE L. OCAY, RN PURPLE ANN P. LABOTAN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
 (STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Benguet General Hospital, La Trinidad Benguet

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

AUGUST 26, 2010 BABY BOY P. IMMEDIATE NEWBORN CORD CARE /

LUZ B. KEDIAM, RN MA THERESA MACARAEG, RN, MAN
9:05 AM 263023 DELIVERY ROOM

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1C
College of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Lepanto Consolidated Mining Company Hospital, Lepanto, Benguet
Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

FEBRUARY 04, 2011 BABY GIRL A. IMMEDIATE NEWBORN CORD CARE /

HEIDI A. MONTOYA, RN NELLIE C. PALGUE, RN
9:00 AM 11107 DELIVERY ROOM

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Tagudin General Hospital and Capillariasis Center, Tagudin, Ilocos Sur
Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R. Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

MAY 16, 2010 BABY BOY J. IMMEDIATE NEWBORN CORD CARE /

CRESENCIA . ANDRES, RM JESUS P. ANIBAN, RN, MAN
7:02 PM 082898 DELIVERY ROOM

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)
 UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Pozorrubio Municipal Hospital, Pozorrubio, La Union

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

NOVEMBER 13, 2010 BABY BOY R. IMMEDIATE NEWBORN CORD CARE /

ELENA B. TADEO, RN PURPLE ANN P. LABOTAN
3:59 AM 062047 DELIVERY ROOM

NOVEMBER 20, 2010 BABY GIRL G. IMMEDIATE NEWBORN CORD CARE /

062319 DELIVERY ROOM MELANIE L. OCAY, RN PURPLE ANN P. LABOTAN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
 (STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Pozorrubio Municipal Hospital, Pozorrubio, La Union

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

NOVEMBER 13, 2010 BABY BOY R. IMMEDIATE NEWBORN CORD CARE /

ELENA B. TADEO, RN PURPLE ANN P. LABOTAN
3:59 AM 062047 DELIVERY ROOM

NOVEMBER 20, 2010 BABY GIRL G. IMMEDIATE NEWBORN CORD CARE /

062319 DELIVERY ROOM ELENA B. TADEO, RN PURPLE ANN P. LABOTAN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
 (STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Pozorrubio Municipal Hospital, Pozorrubio, La Union

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

NOVEMBER 13, 2010 BABY BOY R. IMMEDIATE NEWBORN CORD CARE /

ELENA B. TADEO, RN PURPLE ANN P. LABOTAN
3:59 AM 062047 DELIVERY ROOM

NOVEMBER 20, 2010 BABY GIRL G. IMMEDIATE NEWBORN CORD CARE /

062319 DELIVERY ROOM MELANIE L. OCAY, RN PURPLE ANN P. LABOTAN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
 (STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Pozorrubio Municipal Hospital, Pozorrubio, La Union

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

NOVEMBER 13, 2010 BABY BOY R. IMMEDIATE NEWBORN CORD CARE /

ELENA B. TADEO, RN PURPLE ANN P. LABOTAN
3:59 AM 062047 DELIVERY ROOM

NOVEMBER 20, 2010 BABY GIRL G. IMMEDIATE NEWBORN CORD CARE /

062319 DELIVERY ROOM ELENA B. TADEO, RN PURPLE ANN P. LABOTAN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
 (STRICTLY NO DESIGNATES)

UNIVERSITY OF BAGUIO
ODC Form 1C
School of Nursing CORD CARE FORM
Upper General Luna Road, 2600 Baguio City
Tel. #: (074) 442-4915, 442-3036; Fax #: 074 (442-3071); E-Mail: ub@ubaguio.edu

IMMEDIATE NEWBORN CARE in Pozorrubio Municipal Hospital, Pozorrubio, La Union

Hospital/Home/Lying-in-Clinic, Municipal/City/Province
Prepared by:
Printed Name and Signature of Student: MAYLENE R. FERNANDEZ

Patient’s INITIALS Only

Date Performed Immediate Newborn Cord Care D.R./Nursery Nurse On Duty SUPERVISED BY
and Case Number PERFORMED (indicate where performed e.g. (Name and Signature) Clinical Instructor
Time Started (Not Applicable for Birthing D.R., Nursery, NICU or Home) (If Midwife on Duty, Signature NOT Required) (Name and Signature)
Homes/Lying-in Clinics/Homes

NOVEMBER 13, 2010 BABY BOY R. IMMEDIATE NEWBORN CORD CARE /

JANVIC NERRIE C. GOBOT, RN PURPLE ANN P. LABOTAN
3:59 AM 062047 DELIVERY ROOM

NOVEMBER 20, 2010 BABY GIRL G. IMMEDIATE NEWBORN CORD CARE /

062319 DELIVERY ROOM MELANIE L. OCAY, RN PURPLE ANN P. LABOTAN

Noted by: Approved by:

HELEN D. ALALAG R.N., M.A.N. JOCELYN A. APALLA RN, M.C.D., M.A.N.

Clinical Coordinator Dean
PRC I.D No: 0276143 Valid Until: November 15, 2011 PRC I.D. No: 0158259 Valid Until: December 19, 2011
PNA No: 015248 Valid Until: October 31, 2011 PNA No: 18208 Valid Until: Life member
Date document is signed: _____________Time:__________ ADPCN No: 0902 Valid Until: May 31, 2011
Highest Nursing Degree Earned: Master of Arts in Nursing Date document is signed: ______________ Time: ____________
Highest Nursing Degree Earned: Masters in Community Development
Master of Arts in Nursing
(STRICTLY NO DESIGNATES)