Special notes: Please make sure that there are 1. Alloted spaces for signature 2.

No abbreviation or acronyms for the procedures. 3. Correct spelling of those who will sign especially for those cases from manila 4. Complete address of the different hospitals. 5. Yung license ni Mam Babeth di na po ata 2012 ang expiration.. 2015 na po ata. 6. Sana mapasign na po mga to before the start of their in house, para di hassle sa inyo at sa mga students. ALL THE BEST!!!

St. Paul University Philippines

Mabini St., Tuguegarao City, Cagayan 3500 844-1863/846-4444, Fax No. 844-9186, spup_global@yahoo.com PAASCU Level 3, August 2007- November 2011 ISO 9001-2000 Certified

ODC Form 1A ACTUAL DELIVERY FORM

ACTUAL DELIVERY in DR. JOSE REYES MEMORIAL MEDICAL CENTER, SAN LAZARO COMPOUND RIZAL AVENUE ST., STA. CRUZ, MANILA Prepared by:
Date Performed and Time Started

PRECIOUS ANGELIQUE A. DY Patients INITIALS Only Case Number

(not applicable for Birthing/Lying in Clinics/Homes)

PROCEDURE PERFORMED

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) JOANNE CAMILLE DELOS SANTOS,RN

SUPERVISED BY Clinical Instructor Name and Signature

12/24/10 12:15 PM

R.B. 582359

NORMAL SPONTANEOUS DELIVERY

DHONNA CRUZ CAMBE, RN,RM,MAN

Noted by: CATHERINE L. VERZOSA, MSN Clinical Coordinator, PRC ID No. 0089170 Valid Until June 29, 2014 Date Document is signed: __ Time: Highest Nursing Degree Earned: Masters of Science in Nursing

Approved by: MA. ELIZABETH C. BAUA, DNS Dean, PRC ID No. 0100755 Valid Until February 15, 2012 Date Document is signed: Time: Highest Nursing Degree Earned: Doctor of Nursing Science

St. Paul University Philippines

Mabini St., Tuguegarao City, Cagayan 3500 844-1863/846-4444, Fax No. 844-9186, spup_global@yahoo.com PAASCU Level 3, August 2007- November 2011 ISO 9001-2000 Certified

ODC Form 1B ASSISTED DELIVERY FORM

ASSISTED DELIVERY in DR. JOSE REYES MEMORIAL MEDICAL CENTER, SAN LAZARO COMPOUND RIZAL AVENUE ST., STA. CRUZ, MANILA Prepared by:
Date Performed and Time Started

PRECIOUS ANGELIQUE A. DY Patients INITIALS Only Case Number

(not applicable for Birthing/Lying in Clinics/Homes)

PROCEDURE PERFORMED

ASSISTED DELIVERY
12/23/10 9:10 AM M.I. 664514 NORMAL SPONTANEOUS DELIVERY

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) JOANNE CAMILLE DELOS SANTOS,RN

SUPERVISED BY Clinical Instructor Name and Signature

DHONNA CRUZ CAMBE, RN,RM,MAN

Noted by: CATHERINE L. VERZOSA, MSN Clinical Coordinator, PRC ID No. 0089170 Valid Until June 29, 2014 Date Document is signed: __ Time: Highest Nursing Degree Earned: Masters of Science in Nursing

Approved by: MA. ELIZABETH C. BAUA, DNS Dean, PRC ID No. 0100755 Valid Until February 15, 2012 Date Document is signed: Time: Highest Nursing Degree Earned: Doctor of Nursing Science

St. Paul University Philippines

Mabini St., Tuguegarao City, Cagayan 3500 844-1863/846-4444, Fax No. 844-9186, spup_global@yahoo.com PAASCU Level 3, August 2007- November 2011 ISO 9001-2000 Certified

ODC Form 1C CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in DR. JOSE FABELLA MEMORIAL HOSPITAL, LOPE DE VEGA ST., STA. CRUZ, MANILA Prepared by: PRECIOUS ANGELIQUE A. DY
Date Performed and Time Started Patients INITIALS Only

Case Number
(not applicable for Birthing Homes /Lying in Clinics/Homes)

Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home BB. GIRL D.R. FABELLA

D.R Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required) MARIBEL MARCELINO,RN

SUPERVISED BY Clinical Instructor Name and Signature

12/27/10 6:17AM

A.D. 388098

MIRIAM PATTUGALAN,RN,MSN

Noted by: CATHERINE L. VERZOSA, MSN Clinical Coordinator, PRC ID No. 0089170 Valid Until June 29, 2014 Date Document is signed: __ Time: Highest Nursing Degree Earned: Masters of Science in Nursing

Approved by: MA. ELIZABETH C. BAUA, DNS Dean, PRC ID No. 0100755 Valid Until February 15, 2012 Date Document is signed: Time: Highest Nursing Degree Earned: Doctor of Nursing Science

St. Paul University Philippines

Mabini St., Tuguegarao City, Cagayan 3500 844-1863/846-4444, Fax No. 844-9186, spup_global@yahoo.com PAASCU Level 3, August 2007- November 2011 ISO 9001-2000 Certified

ODC Form 2A O.R. SCRUB FORM MAJOR

SURGICAL SCRUB in DR. JOSE REYES MEMORIAL MEDICAL CENTER, SAN LARAZO COMPOUND RIZAL AVENUE ST., STA. CRUZ, MANILA Prepared by: PRECIOUS ANGELIQUE A. DY
Date Performed and Time Started Patients INITIALS (only)

Case Number M.G.R. 604872

SURGICAL PROCEDURE PERFORMED

PRIMARY LOW SEGMENT CAESARIAN SECTION

O.R Nurse On Duty (Name AND Signature)

SUPERVISED BY Clinical Instructor Name and Signature

JOSEPH T. GATCHALIAN, RN, MAN

12/27/10 2:30 PM

CHRISTIAN POLINAG, RN

Noted by: CATHERINE L. VERZOSA, MSN Clinical Coordinator, PRC ID No. 0089170 Valid Until June 29, 2014 Date Document is signed: __ Time: Highest Nursing Degree Earned: Masters of Science in Nursing

Approved by: MA. ELIZABETH C. BAUA, DNS Dean, PRC ID No. 0100755 Valid Until February 15, 2012 Date Document is signed: Time: Highest Nursing Degree Earned: Doctor of Nursing Science

St. Paul University Philippines

Mabini St., Tuguegarao City, Cagayan 3500 844-1863/846-4444, Fax No. 844-9186, spup_global@yahoo.com PAASCU Level 3, August 2007- November 2011 ISO 9001-2000 Certified

ODC Form 2B O.R. MINOR FORM

SURGICAL SCRUB in CAGAYAN VALLEY MEDICAL CENTER, CARIG SUR, TUGUEGARAO CITY, CAGAYAN Prepared by: PRECIOUS ANGELIQUE A. DY
Date Performed and Time Started Patients INITIALS (only)

Case Number R.J. 60013

SURGICAL PROCEDURE PERFORMED

EMERGENCY DEDRIDEMENT TENORRHAPHY LEFT

O.R Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature MIRIAM PATTUGALAN, RN, MSN

03/04/10 4:30 PM

MANUEL CORTEZ, RN

Noted by: CATHERINE L. VERZOSA, MSN Clinical Coordinator, PRC ID No. 0089170 Valid Until June 29, 2014 Date Document is signed: __ Time: Highest Nursing Degree Earned: Masters of Science in Nursing

Approved by: MA. ELIZABETH C. BAUA, DNS Dean, PRC ID No. 0100755 Valid Until February 15, 2012 Date Document is signed: Time: Highest Nursing Degree Earned: Doctor of Nursing Science