Name of Student Name and Address of School Recognition and Accreditation Level (if any) Date School/Program was

Recognized:

: Laruta, Anna Grace Basa : Gordon College - College of Nursing Old Hospital Road, East Tapinac, Olongapo City : Year Granted 2004 Number 3 Year 2004

First Course (if any) School Graduated From Year of Admission in the BSN Program Year Graduated from the BSN Program

: : : 2007 : 2011

Year:

I.
No . Date of Operation Case No. Name of Patient Diagnosis

Major Operations
Types of Anesthesia Name of Surgeon Name of Hospital San Marcelino District Hospital Name of O.R. Scrub Nurse Signature of O.R Scrub Nurse

Operation Performed

1.

May 07, 2010

346 034

Astraquillo, Marlene

PUFT IL g1p0 37 2/7 wks. AOG by UTZ, Preeclampsia

Caesarean Section

Spinal anaesthesia

Dr. Margarita Ciervo

2. 3. 4. 5. Concurred by: Concurred by: Approved by: Noted by:

Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing :

Dean Vizsabelle D. Pielago RN, MAN Signature over printed name of Dean Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing :

, BSN, RN, MAN Signature over printed name of Clinical coordinator Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing

Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing,
Registered Nurse, Master of Arts in Nursing

a) PRC

a) PRC No.

a) PRC No.

a) PRC No.

No. Valid until b) PNA No. Valid until

: : :

Valid until b) PNA No. Valid until c) ADCPN No. Valid until

: : : : :

Valid until b) PNA No. Valid until

: : :

Valid until b) PNA No. Valid until

: : :

PREPARED BY:

: Signature over Name of Student

Name of Student Name and Address of School Recognition and Accreditation Level (if any) Date School/Program was Recognized:

: : :

Laruta, Anna Grace Basa Gordon College - College of Nursing Old Hospital Road, East Tapinac, Olongapo City Year Granted 2004 Number 3 Year 2004

First Course (if any) School Graduated From Year of Admission in the BSN Program Year Graduated from the BSN Program

: : : :

Year: 2007 2011

No .
1. 2. 3. 4. 5.

Date of Operati on

Case No.

Name of Patient

Diagnosis

Operation Performed

II. Minor Operations Types of Name of Anesthesi Surgeon a

Name of Hospital

Name of O.R. Scrub Nurse

Signature of O.R Scrub Nurse

Concurred by: by:

Approved by:

Noted by:

Concurred

Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing

Dean Vizsabelle D. Pielago RN, MAN Signature over printed name of Dean Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : : : :

, BSN, RN, MAN Signature over printed name of Clinical Coordinator Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : :

Signature over printed name of Chief Nurse

Date Signed Degree

: : Bachelor of Science in Nursing, Registered Nurse, Candidate for Master of Arts in Nursing : : : :

a) PRC No. Valid until b) PNA No. Valid until

: : : :

a) PRC No. Valid until b) PNA No. Valid until c) ADCPN No. Valid until

a) PRC No. Valid until b) PNA No. Valid until

a) PRC No. Valid until b) PNA No. Valid until

EPARED BY:

: Signature over Name of Student

Name of Student Name and Address of School

: : Gordon College - College of Allied Medical Studies Old Hospital Road, East Tapinac, Olongapo City : Year Granted 2004 Number 3 Year 2004

First Course (if any) School Graduated From Year of Admission in the BSN Program Year Graduated from the BSN Program

: : : 2006 : 2010

Year:

Recognition and Accreditation Level (if any) Date School/Program was Recognized:

III.
No. Case No. Date Performe d Diagnosis Name of Mother

Actual Deliveries
Age Gende r of Baby Time of Delive ry Type of Delivery Name of Hospital Supervised by: Name and Signature of Qualified C.I.

1.

2. 3. 4. 5. Concurred by: Concurred by: Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : : Approved by: Dean Vizsabelle D. Pielago RN, MAN Signature over printed name of Dean Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : : : : Noted by: , BSN, RN, MAN Signature over printed name of Clinical Coordinator Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : : until

Signature over printed name of Chief Nurse

Date Signed Degree

: : Bachelor of Science in Nursing, Registered Nurse, Candidate for Master of Arts in Nursing : : : :

a) PRC No. Valid until b) PNA No. Valid until

a) PRC No. Valid until b) PNA No. Valid until c) ADCPN No. Valid until

a) PRC No. Valid until b) PNA No. Valid until

a) PRC No. Valid until b) PNA No. Valid

PREPARED BY:

: Signature over Name of Student

Name of Student Name and Address of School

: : Gordon College - College of Allied Medical Studies Old Hospital Road, East Tapinac, Olongapo City

First Course (if any) School Graduated From Year of Admission in the BSN Program

: : : 2006

Year:

Recognition and Accreditation Level (if any) Date School/Program was Recognized:

: Year Granted 2004 Number 3 Year 2004

Year Graduated from the BSN Program

: 2010

IV.
N o. Case No. Diagnosis Name of Patient Age

Deliveries Assisted
Time of Delive ry Gende r of Baby Name of Hospital Type of Delivery Supervised by: Name and Signature of Qualified C.I.

Date of Delivery

1. 2. 3. 4. 5. Concurred by: by: Dean Vizsabelle D. Pielago RN, MAN Signature over printed name of Dean Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : : : : , BSN, RN, MAN Signature over printed name of Clinical Coordinator printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing,
Registered Nurse, Master of Arts in Nursing Date Signed

Approved by:

Noted by:

Concurred

Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing : : : :

Signature over

: : Bachelor of Science in Nursing, Registered

Nurse, Master of Arts in Nursing / Bachelor of Science in Nursing, Registered Nurse

Degree

a) PRC No. Valid until b) PNA No. Valid until

a) PRC No. Valid until b) PNA No. Valid until c) ADCPN No. Valid until

a) PRC No. Valid until b) PNA No. Valid until

: : : :

a) PRC No. Valid until b) PNA No. Valid until

: : : :

PREPARE D BY:

: Signature over Name of Student

Name of Student Name and Address of School

: : Gordon College - College of Allied Medical Studies Old Hospital Road, East Tapinac, Olongapo City : Year Granted 2004 Number 3 Year 2004

First Course (if any) School Graduated From Year of Admission in the BSN Program Year Graduated from the BSN Program

: : : 2006 : 2010

Year:

Recognition and Accreditation Level (if any) Date School/Program was Recognized:

V.
No. 1. 2. 3. 4. 5. Concurred by: Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing Approved by: Case No. Date Performed Name of Baby Gender of Baby

Cord Dressing
Age Name of Hospital Supervised by: Name and Signature of Qualified C.I.

Name of Mother

Noted by: , BSN, RN, MAN Signature over printed name of Clinical Coordinator Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing

Concurred by: Signature over printed name of Chief Nurse Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Candidate for Master of Arts in

Dean Vizsabelle D. Pielago RN, MAN Signature over printed name of Dean Date Signed Degree : : Bachelor of Science in Nursing, Registered Nurse, Master of Arts in Nursing

Nursing a) PRC No. Valid until b) PNA No. Valid until : : : : a) PRC No. Valid until b) PNA No. Valid until c) ADCPN No. Valid until Signature over Name of Student : : : : : : a) PRC No. Valid until b) PNA No. Valid until : : : : a) PRC No. Valid until b) PNA No. Valid until : : : :

PREPARED BY:

INSTRUCTIONS: All cases must be encoded in the above template and properly acknowledged /signed by your Clinical Instructors or Scrub Nurse. Midwives or Surgical Intern / Surgical Resident Doctor / Surgeon are not allowed to sign in behalf of the scrub nurse. Once completed a case, please document it and ask your scrub nurse or Clinical Instructor to sign this form. All pertinent data must be obtained and be encoded properly. Initially, it is alright in accomplishing this form using your hand writing. No abbreviation of medical diagnosis must be practiced. Signature of the Chief Nurse is only required when all cases are completed. This template is an official form of the college therefore any alterations, manipulations are not allowed. Consolidate all cases with same case (all major operation in one sheet even though cases come from different hospitals). Maintain one soft copy and one hard copy of this form so that editing later on is easier.