Name of Student: _____________________________________________________________________________________________________________________________________________________________________________ Name and Address of School: __________________________________________________________________________________________________________________________________________________________________ Accreditation Level: (if any) Year Granted _______________________________________________________________________________________________________________________

_______ Year ________________________________________________________________________________________ Date School/Program was Recognized: __________ Number First Course (if any): School Graduated From: Year ________________________________________________________________________________ Year Admission in the Bachelor of Science in Nursing Program: ________________________________________________________________________________________________________________________ Year Graduated (BSN Program): __________________________________________________________________________________________________________________________________________________________

I. Major Operations
No. Date of Operation Case No. Name of Patient Diagnosis Operation Performed Type of Anesthesia Name of Surgeon Name of Hospital Name of Clinical Instructor

1.

September 3, 2009

090829

Christine Joy Plata

Pregnancy Uterine Full Term 38 weeks Age of Gestation, Cephalic in Labor, Cepahlo Pelvic Disproportion, Gravida 3 Para 2 Cholelithiasis

Repeat Lower Segment Cesarian Section

Sub-arachnoid Block Anesthesia

Dra. Melissa Lim

Saint Patricks Hospital Medical Center

Geralyn H. Custodio

2. 3.

January 4, 2011 August 10, 2010 September 4, 2009

110093 312917

Isidro Atienza Ricardo Sanchez Rayos Gina Tolentino

Cholecystectomy

Epidural Anesthesia Sub-arachnoid Block Anesthesia General Endotracheal Tube Anesthesia Sub-arachnoid Block Anesthesia

Dr. Norberto Malibiran Dr. Jonathan Mangubat Dr. Roy Berberabe

Our Lady of Caysasay Medical Center Batangas Provincial Hospital Saint Patricks Hospital and Medical Center

Baby Brenda C. Luna Maxima E. Mayuga

Cystolithiasis

Cystoscopy, Cystolithotomy, Transvesical Ureterolithotomy Completion Thyroidectomy Total

4.

101147

Recurrent Nodular Non-Toxic Goiter Right Status Post Thyroidectomy

Geralyn H. Custodio

5.

August 11, 2010

308498

Julieta Anchoreg

Ovarian New Growth

Exploratory Laparotomy, Oophorectomy R

Dr.Buenaventur a Magboo

Batangas Provincial Hospital

Maxima E. Mayuga

Prepared by:_________________________________________ DIMAILIG, JOCELYN TENORIO Signature over printed Name of Student Supervised by: _ ______________________ Signature over printed Name of Clinical Instructor Date Signed: Degree: ________________ a.) PRC No.:___ _________ _______ Valid until: ____ __________ _ b.) PNA No.:_ __________ _ Valid until: ___ ___________ _______ Concurred by: __________________________ Signature over printed Name of Chief Nurse Date Signed: Degree: _________ a.) PRC No. ________ Valid until _________ b.) PNA No.: ___________ Valid until: ______________ __ _ Noted by: ___________________ ______ Signature over printed Name of Clinical Coordinator Date Signed: _ Degree: _________ a.) PRC No.: _______ Valid until: _ ________________ b.) PNA No.: ________ Valid until: _____________ Approved by: Ms. Bernadette B. Reyes___ Signature over printed Name of Dean Date Signed: Degree: R.N, R.M, M.A.N. a) PRC No.: 0156431 Valid until: January 8, 2012 b) PNA No.: 010895 Valid until: Lifetime c.) ADPCN No.: 0269 Valid until: May 2012

Name of Student: __________________________________ Name and Address of School: _________________________________ Accreditation Level: (if any) Year Granted Date School/Program was Recognized: Number School Graduated From: First Course (if any): Year Admission in the Bachelor of Science in Nursing Program: Year Graduated (BSN Program):

Year ________ Year

________________

________

II. Minor Operations

No.

Date of Operation August 9, 2010

Case No. 308906

Name of Patient

Diagnosis

Operation Performed Excission of Granuloma Toenail L

Type of Anesthesia Local Anesthesia

Name of Surgeon

Name of Hospital

Name of Clinical Instructor Maxima E. Mayuga

1.

Maria Vianney Salazar Maria Corazon Fernandez Shiela Margarita

Granuloma Left Toenail

Dr. Ramon Sixto Castillo

Batangas Provincial Hospital

2.

January 7, 2011

110085

Status Post Total Abdominal Hysterectomy Salphingo Oophorectomy, Ovarian Cancer Acute Appendicitis

Insertion of Peritoneal Tube Appendectomy

Sub-arachnoid Block Anesthesia Sub-arachnoid Block Anesthesia Local Anesthesia

Dr. Albert Go

Our Lady of Caysasay Medical Center Batangas Provincial Hospital

Baby Brenda C. Luna Maxima E. Mayuga

3.

August 11, 2010

312424

Dr. Ramon Sixto Castillo

4.

September 4, 2009 August 12, 2010

101115

Mario Hernandez

Lacerated wound Fourth Finger Left Lacerated Wound Tongue

Suturing of Lacerated Wound 4th Finger L Debridement, Repair of Tongue

Dr. Ramon Pastor

Saint Patricks Hospital Medical Center Batangas Provincial Hospital

Geralyn H. Custodio Maxima E. Mayuga

5.

309771

Justine Ivan Mayuga

Intravenous Sedation Anesthesia

Dr. Danilo Aguilera

Prepared by:

________________________________________ PERMEJO, ELLECER ANTHONY MANDIGMA Signature over printed Name of Student Concurred by: _________________________ Signature over printed Name of Nursing Director Date Signed: Degree__________________ a.) PRC No. _______ Valid until _______________ b.) PNA No.: _______ Valid until: _________________ Noted by: __________________ Signature over printed Name of Clinical Coordinator Date Signed: __ Degree: _______ __ a.) PRC No.: _______ Valid until: _ _________________ b.) PNA No.: _____________________ Valid until: ______________ __ Approved by: Ms. Bernadette B. Reyes___ Signature over printed Name of Dean Date Signed: Degree: RN, RM, MAN a) PRC No.: 0156431 Valid until: January 8, 2012 b) PNA No.: 010895 Valid until: Lifetime c.) ADPCN No.: 0269 Valid until: May 2012

Supervised by: __________________ Signature over printed Name of Clinical Instructor Date Signed: Degree: _________ a.) PRC No.:___ _____ Valid until: ____ __________________ b.) PNA No.:_ __________ Valid until: ___ ________

Name of Student: __________________________________ Name and Address of School: ______________________________________________ Year Granted Accreditation Level: (if any) Date School/Program was Recognized: _______________ Number ___________ First Course (if any): School Graduated From: Year Admission in the Bachelor of Science in Nursing Program: Year Graduated (BSN Program):

________

Year Year

III. Actual Deliveries

No.

Case No.

Diagnosis

Name of Mother

Age

Date of Delivery

Time of Delivery

Gender of Baby

Name of Hospital

Type of Delivery

Name of Clinical Instructor

1.

31-1334

Pregnancy Uterine Full Term, 37 weeks Age of gestation, Cephalic In Labor Gravida 1 Para 0 Pregnancy Uterine Full Term, 38 weeks Age of Gestation, Cephalic In Labor Gravida 1 Para 0 Pregnancy Uterine Full Term, 37weeks Age of Gestation,Cephalic In Labor, Gravida 2 Para 1 Pregnancy Uterine Full Term, 40 weeks Age of Gestation, Cephalic In Labor, Gravida 2 Para 1 Pregnancy Uterine Full Term, 38 weeks Age of gestation, Cephalic In Labor, Gravida 1 Para 0

Arlene Adan

18y/o

October 04, 2010

11:57 am

Female

Batangas Provincial Hospital

Normal Spontaneous Delivery

Maxima E. Mayuga

2.

31-1349

Melanie Adajar

20y/o

October 05, 2010

1:15 pm

Male

Batangas Provincial Hospital Batangas Provincial Hospital Batangas Provincial Hospital Batangas Provincial Hospital

Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

Maxima E. Mayuga Maxima E. Mayuga Maxima E. Mayuga Maxima E. Mayuga

3.

31-1384

Maria Odeza Bianca Cuento Marie Castro

25y/o

August 09, 2010

11:45 am 2:10 pm

Male

4.

31-1417

22y/o

August 11, 2010 August 2, 2010

Male

5.

31-1461

Karen Abi o

23y/o

12:05pm

Female

Prepared by: __________________________________________ PERMEJO, ELLECER ANTHONY MANDIGMA Signature over printed Name of Student Supervised by: ________________________ Signature over printed Name of Clinical Instructor Date Signed: Degree: ________________ a.) PRC No.:___ _________ Valid until: ____ ______________ _ b.) PNA No.:_ ________________ Valid until: ___ _______________ Concurred by: _____________________ Signature over printed Name of Chief Nurse Date Signed: Degree: ______ a.) PRC No. ______ Valid until ______________ b.) PNA No.: _______________ Valid until: _____________ Noted by: ________________________________ Signature over printed Name of Clinical Coordinator Date Signed: __ Degree: __________________ __ a.) PRC No.: _______ Valid until: _________________ b.) PNA No.: ______ Valid until: ___________ __ Approved by: Ms. Bernadette B. Reyes___ Signature over printed Name of Dean Date Signed: Degree: RN, RM, MAN a) PRC No.: 0156431 Valid until: January 8, 2012 b) PNA No.: 010895 Valid until: Lifetime c.) ADPCN No.: 0269 Valid until: May 2012

_ _ _ _

Name of Student: _________________________________________ Name and Address of School: ___________________________________ Year Granted Accreditation Level: (if any) Date School/Program was Recognized: _________________ Number First Course (if any): School Graduated From: Year Admission in the Bachelor of Science in Nursing Program: Year Graduated (BSN Program):

________

Year Year

__________________

IV. Deliveries Assisted

No.

Case No.

Diagnosis

Name of Mother

Age

Date of Delivery
October 6, 2010

Time of Delivery
7:03 am 2:30 pm

Gender of Baby
Female

Name of Hospital

Type of Delivery

Name of Clinical Instructor

Maxima E. Mayuga

1. 2.

31-2330

Pregnancy Uterine Full Term, 39 Weeks Age of Gestation, Cephalic In Labor, Gravida 1 Para 0 Pregnancy Uterine Full Term, 37 1/7 weeks Age of Gestation, Cephalic In Labor Gravida 2 Para 1 Pregnancy Uterine Full Term, 39 weeks Age of Gestation, Cephalic In Labor, Gravida 2 Para 1 Pregnancy Uterine Full Term, 39 weeks Age of Gestation, Cephalic In Labor, Gravida 1 Para 0 Pregnancy Uterine Full Term, 40 weeks Age of Gestation, Cephalic In Labor, Gravida 3 Para 2

Rosemarie Lopez

18y/o 21y/o

Batangas Provincial Hospital Batangas Provincial Hospital

Normal Spontaneous Delivery Normal Spontaneous Delivery

31-2207

Anna May Tongon

August 10, 2010

Male

Maxima E. Mayuga

3.

31-2820

Edel Catipon

23y/o

October 5, 2010

11:49 am

Male

Batangas Provincial Hospital Our Lady Of Caysasay Medical Center Batangas Provincial Hospital

Normal Spontaneous Delivery Normal Spontaneous Delivery

Maxima E. Mayuga

4.

11-0023

29y/o Luzviminda Manalo

January 3, 2011

8:40 am

Male

Baby Brenda C. Luna

5.

31-3017

Mery Joy MAramot

21y/o

August 11, 2010

9:10 am

Male

Normal Spontaneous Delivery

Maxima E. Mayuga

Prepared by: _________________________________________ PERMEJO, ELLECER ANTHONY MANDIGMA Signature over printed Name of Student Supervised by: ______________ Signature over printed Name of Clinical Instructor Date Signed: Degree: R.N. M.A.N a.) PRC No.:___ 00267164 Valid until: ___ May 29, 2014 b.) PNA No.:_ 2011-076068 Valid until: ___ October 31, 2011 Concurred by: ___________ _ __________ Signature over printed Name of Chief Nurse Date Signed: __ Degree: _________ _ a.) PRC No. __________ __ Valid until _______________ b.) PNA No.: ___________________ Valid until: _____________________ Noted by: _______________________ Signature over printed Name of Clinical Coordinator Date Signed: __ Degree: ____________________ __ a.) PRC No.: ___ Valid until: _ _________________ b.) PNA No.: _______________ Valid until: ___________ __ Approved by: Ms. Bernadette B. Reyes___ Signature over printed Name of Dean Date Signed: Degree: RN, RM, MAN a) PRC No.: 0156431 Valid until: January 8, 2012 b) PNA No.: 010895 Valid until: Lifetime c.) ADCPN No.: 0269 Valid until: May 2012

Name of Student: PERMEJO, ELLECER ANTHONY MANDIGMA Name and Address of School: University of Batangas, Hilltop, Batangas City Accreditation Level: (if any) LEVEL 1 Year Granted 2010 Number No. 023 s. 1997 Date School/Program was Recognized: April 11, 1997 First Course (if any): N/A School Graduated From: Year Admission in the Bachelor of Science in Nursing Program: 2007 Year Graduated (BSN Program): 2011

N/A

Year Year

1997 N/A

V. Cord Dressing

No.

Case No.

Date Performed

Name of Baby

Gender of Baby

Name of Mother

Age

Name of Hospital

Name of Clinical Instructor

1.

110192

January 4, 2011

Baby Girl of Helen Pesigan Baby Boy of Manilyn Bitong Baby Girl of Jennelyn Albania Baby Girl of Fatima Bagasala Baby Boy of Cristy Villena

Female

Helen Pesigan

37 y/o

Our Lady of Caysasay Medical Center

Baby Brenda C. Luna

2. 3. 4. 5.

110038 110131 312961 3133066

January 6, 2011 January 3, 2011 August 11, 2010 August 10, 2010

Male Female Female Male

Manilyn Bitong Jennelyn Albania Fatima Bagasala Cristy Villena

23y/o 25 y/o 21 y/o 23 y/o

Our Lady of Caysasay Medical Center Our Lady of Caysasay Medical Center Batangas Provincial Hospital Batangas Provincial Hospital

Baby Brenda C. Luna Baby Brenda C. Luna Maxima E. Mayuga Maxima E. Mayuga

Prepared by: _________________________________________ PERMEJO, ELLECER ANTHONY MANDIGMA Signature over printed Name of Student

Supervised by: Mrs. Baby Brenda C. Luna Signature over printed Name of Clinical Instructor Date Signed: Degree: R.N. M.A.N (units) a.) PRC No.:___ 0185217 Valid until: ____ September 18, 2012 _ b.) PNA No.:_ 2011-047727 Valid until: ___ October 31, 2011___

Concurred by: _________________ Signature over printed Name of Nursing Director Date Signed: Degree: R.N. M.A.N. a.) PRC No. 0130085 Valid until February 17, 2012 b.) PNA No.: 2011-037488 Valid until: October 31, 2011

Noted by: _______________________ Signature over printed Name of Clinical Coordinator Date Signed: _ Degree: ________________________________ _ a.) PRC No.: 0202363 Valid until: _November 12, 2013 b.) PNA No.: 2011-047751 Valid until: October 31, 2011 _

Approved by: Ms. Bernadette B. Reyes___ Signature over printed Name of Dean Date Signed: Degree: RN, RM, MAN a) PRC No.: 0156431 Valid until: January 8, 2012 b) PNA No.: 010895 Valid until: Lifetime c.) ADPCN No.: 0269 Valid until: May 2012

__ __

SUBSCRIBED AND SWORN to before me this__________________________________at_____________________________________