Blank Case Template
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Name of Student Name and Address of School ________________
: _________________ : ____________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
_______
___________________________________ : _____________ : ___________________
First Course (if any) School Graduated From
: :
Year:
Year of Admission in the BSN Program : ____ Year Graduated from the BSN Program : ____
________________
I. Major Operations No .
Date of Operati on
Case No.
Name of Patient
Diagnosis
Operation Performed
Types of Anesthe sia
Name of Surgeon
Name of Hospital
Name of O.R. Scrub Nurse
Signature of O.R. Scrub Nurse
1. 2. 3. 4. 5.
Noted by:
Noted by:
Approved by:
Zenaida Torrente, RN, MAN
Ligaya Paragas, BSN, RN, MAN Signature and Printed Name of Clinical Coordinator Signature Over Printed Name of Dean
Date Signed : Degree : Bachelor of Science in Nursing, in Nursing of ________ Arts in Nursing a) PRC No. : 0053516 Valid until : January 3, 2011 b) PNA No. : 17874 Valid until : Lifetime PREPARED BY:
__________________ _____ Signature over Name of Student
Date Signed ________
: Degree
Dean Vizsabelle D. Pielago, RN, MAN Signature and Printed Name of Chief Nurse
Date Signed : : Bachelor of Science in Nursing, ________ Registered Nurse, Master of ________
Registered Nurse, Master of Arts in Nursing a) PRC No. : 0129700 Valid until : July 6, 2010 b) PNA No. : 009221 Valid until : December 2009
Degree
: Bachelor of Science Registered Nurse, Master
Arts in Nursing a) PRC No. : 0075654 Valid until : January 2011 b) PNA No. : 004404 Valid until : December 2009 c) ADCPN No. : 0411 Valid until : December 2009
Name of Student Name and Address of School ________
:__________________ : ___________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
No .
Date of Operatio n
Case No.
___________________________________ : ____________ : ___________________
Name of Patient
First Course (if any) School Graduated From
________
:
Year of Admission in the BSN Program : ____ Year Graduated from the BSN Program :
II. Minor Operations Types Operation of Performed Anesthe sia
Diagnosis
:
Name of Surgeon
Name of Hospital
Year: ________________
Name of O.R. Scrub Nurse
Signature of O.R. Scrub Nurse
1. 2. 3. 4. 5. Noted by:
Noted by:
Approved by:
Zenaida Torrente, RN, MAN
Ligaya Paragas, BSN, RN, MAN Signature and Printed Name of Clinical Coordinator Signature Over Printed Name of Dean
Date Signed : Degree : Bachelor of Science in Nursing, in Nursing of ________ Arts in Nursing a) PRC No. : 0053516 Valid until : January 3, 2011 b) PNA No. : 17874 Valid until : Lifetime PREPARED BY: _____________________________ Signature over Name of Student
Date Signed ________
: Degree
Dean Vizsabelle D. Pielago, RN, MAN Signature and Printed Name of Chief Nurse
Date Signed : : Bachelor of Science in Nursing, ________ Registered Nurse, Master of ________
Registered Nurse, Master of Arts in Nursing a) PRC No. : 0129700 Valid until : July 6, 2010 b) PNA No. : 009221 Valid until : December 2009
Degree
: Bachelor of Science Registered Nurse, Master
Arts in Nursing a) PRC No. : 0075654 Valid until : January 2011 b) PNA No. : 004404 Valid until : December 2009 c) ADCPN No. : 0411 Valid until : December 2009
Name of Student Name and Address of School ________
: ___________________ : ____________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
First Course (if any) School Graduated From
________
_______________________________________ : __________ : ___________________
: :
Year of Admission in the BSN Program : Year Graduated from the BSN Program :
Year: ________________
III. Actual Deliveries No .
Case No.
Date Performe d
Diagnosis
Name of Mother
Age
Gender of Baby
Time of Delivery
Type of Delivery
Name of Hospital
Supervised by: Name and Signature of Qualified C. I.
1. 2. 3. 4. 5. Noted by:
Noted by:
Zenaida Torrente, RN, MAN Ligaya Paragas, BSN, RN, MAN D. Pielago, RN, MAN Signature and Printed Name of Clinical Coordinator Name of Chief Nurse Signature Over Printed Name of Dean
Noted by: Evelyn Rubia, RN, MAN, PhD Signature and Printed Name of Chief Nurse
Approved by: Dean Vizsabelle Signature Over Printed
Date Signed : Date Signed : Date Signed : Date Signed : Degree : Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Arts in Nursing Arts in Nursing Arts in Nursing Arts in Nursing a) PRC No. : 0053516 a) PRC No. : 0129700 a) PRC No. : 0098006 a) PRC No. : 0075654
Valid until : January 3, 2011 : January 2011 b) PNA No. : 17874 Valid until until
Valid until b) PNA No.
: lifetime : December 2009
: July 6, 2010
Valid until
: 009221
Valid until
b) PNA No.
: December 2009
: October 22, 2011 : 7845
Valid until
Valid until b) PNA No.
: Lifetime
Valid
c) ADCPN No. Valid until PREPARED BY:
: 004404
: 0411 : December 2009
_________________________ Signature over Name of Student
Name of Student Name and Address of School ________
: __________________ : ___________________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
First Course (if any) School Graduated From
_______
______________________________________ : __________________ : ___________________
: :
Year of Admission in the BSN Program : Year Graduated from the BSN Program :
Year: ________________
IV. Deliveries Assisted No .
Case No.
Diagnosis
Name of Patient
Age
Date of Deliver y
Time of Delivery
Gender of Baby
Name of Hospital
Type of Delivery
Supervised by: Name and Signature of Qualified C. I.
1. 2. 3. 4. 5. Noted by:
Noted by:
Zenaida Torrente, RN, MAN Ligaya Paragas, BSN, RN, MAN D. Pielago, RN, MAN Signature and Printed Name of Clinical Coordinator Name of Chief Nurse Signature Over Printed Name of Dean
Noted by: Evelyn Rubia, RN, MAN, PhD Signature and Printed Name of Chief Nurse
Approved by: Dean Vizsabelle Signature Over Printed
Date Signed : Date Signed : Date Signed : Date Signed : Degree : Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Arts in Nursing Arts in Nursing Arts in Nursing Arts in Nursing a) PRC No. : 0053516 a) PRC No. : 0129700 a) PRC No. : 0098006 a) PRC No. : 0075654 Valid until : January 3, 2011 Valid until : July 6, 2010 Valid until : October 22, 2011 Valid until : January 2011 b) PNA No. : 17874 b) PNA No. : 009221 b) PNA No. : 7845 b) PNA No. : 004404 Valid until until
: lifetime : December 2009
Valid until
: December 2009
Valid until
: Lifetime
Valid
c) ADCPN No. Valid until PREPARED BY:
: 0411 : December 2009
________________________ Signature over Name of Student
Name of Student Name and Address of School ________________
: _________________ : ____________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
First Course (if any) School Graduated From
_______
___________________________________ : __________ : ___________________
: :
Year of Admission in the BSN Program : Year Graduated from the BSN Program :
Year: ________________
V. Cord Dressings No . 1. 2.
Case No.
Date Performed
Name of Baby
Gender of baby
Name of Mother
Age
Name of Hospital
Supervised by: Name and Signature of Qualified C. I.
3. 4. 5. Noted by:
Noted by:
Noted by:
Zenaida Torrente, RN, MAN Ligaya Paragas, BSN, RN, MAN D. Pielago, RN, MAN Signature and Printed Name of Clinical Coordinator Name of Chief Nurse Signature Over Printed Name of Dean
Approved by:
Evelyn Rubia, RN, MAN, PhD Signature and Printed Name of Chief Nurse
Dean Vizsabelle Signature Over Printed
Date Signed : Date Signed : Date Signed : Date Signed : Degree : Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Arts in Nursing Arts in Nursing Arts in Nursing Arts in Nursing a) PRC No. : 0053516 a) PRC No. : 0129700 a) PRC No. : 0098006 a) PRC No. : 0075654 Valid until : January 3, 2011 Valid until : July 6, 2010 Valid until : October 22, 2011 Valid until : January 2011 b) PNA No. : 17874 b) PNA No. : 009221 b) PNA No. : 7845 b) PNA No. : 004404 Valid until until
: lifetime : December 2009
Valid until
: December 2009
Valid until
: Lifetime c) ADCPN No. Valid until
PREPARED BY:
_________________________ Signature over Name of Student
Valid : 0411 : December 2009
: _________________ : ____________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
_______
___________________________________ : _____________ : ___________________
First Course (if any) School Graduated From
: :
Year:
Year of Admission in the BSN Program : ____ Year Graduated from the BSN Program : ____
________________
I. Major Operations No .
Date of Operati on
Case No.
Name of Patient
Diagnosis
Operation Performed
Types of Anesthe sia
Name of Surgeon
Name of Hospital
Name of O.R. Scrub Nurse
Signature of O.R. Scrub Nurse
1. 2. 3. 4. 5.
Noted by:
Noted by:
Approved by:
Zenaida Torrente, RN, MAN
Ligaya Paragas, BSN, RN, MAN Signature and Printed Name of Clinical Coordinator Signature Over Printed Name of Dean
Date Signed : Degree : Bachelor of Science in Nursing, in Nursing of ________ Arts in Nursing a) PRC No. : 0053516 Valid until : January 3, 2011 b) PNA No. : 17874 Valid until : Lifetime PREPARED BY:
__________________ _____ Signature over Name of Student
Date Signed ________
: Degree
Dean Vizsabelle D. Pielago, RN, MAN Signature and Printed Name of Chief Nurse
Date Signed : : Bachelor of Science in Nursing, ________ Registered Nurse, Master of ________
Registered Nurse, Master of Arts in Nursing a) PRC No. : 0129700 Valid until : July 6, 2010 b) PNA No. : 009221 Valid until : December 2009
Degree
: Bachelor of Science Registered Nurse, Master
Arts in Nursing a) PRC No. : 0075654 Valid until : January 2011 b) PNA No. : 004404 Valid until : December 2009 c) ADCPN No. : 0411 Valid until : December 2009
Name of Student Name and Address of School ________
:__________________ : ___________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
No .
Date of Operatio n
Case No.
___________________________________ : ____________ : ___________________
Name of Patient
First Course (if any) School Graduated From
________
:
Year of Admission in the BSN Program : ____ Year Graduated from the BSN Program :
II. Minor Operations Types Operation of Performed Anesthe sia
Diagnosis
:
Name of Surgeon
Name of Hospital
Year: ________________
Name of O.R. Scrub Nurse
Signature of O.R. Scrub Nurse
1. 2. 3. 4. 5. Noted by:
Noted by:
Approved by:
Zenaida Torrente, RN, MAN
Ligaya Paragas, BSN, RN, MAN Signature and Printed Name of Clinical Coordinator Signature Over Printed Name of Dean
Date Signed : Degree : Bachelor of Science in Nursing, in Nursing of ________ Arts in Nursing a) PRC No. : 0053516 Valid until : January 3, 2011 b) PNA No. : 17874 Valid until : Lifetime PREPARED BY: _____________________________ Signature over Name of Student
Date Signed ________
: Degree
Dean Vizsabelle D. Pielago, RN, MAN Signature and Printed Name of Chief Nurse
Date Signed : : Bachelor of Science in Nursing, ________ Registered Nurse, Master of ________
Registered Nurse, Master of Arts in Nursing a) PRC No. : 0129700 Valid until : July 6, 2010 b) PNA No. : 009221 Valid until : December 2009
Degree
: Bachelor of Science Registered Nurse, Master
Arts in Nursing a) PRC No. : 0075654 Valid until : January 2011 b) PNA No. : 004404 Valid until : December 2009 c) ADCPN No. : 0411 Valid until : December 2009
Name of Student Name and Address of School ________
: ___________________ : ____________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
First Course (if any) School Graduated From
________
_______________________________________ : __________ : ___________________
: :
Year of Admission in the BSN Program : Year Graduated from the BSN Program :
Year: ________________
III. Actual Deliveries No .
Case No.
Date Performe d
Diagnosis
Name of Mother
Age
Gender of Baby
Time of Delivery
Type of Delivery
Name of Hospital
Supervised by: Name and Signature of Qualified C. I.
1. 2. 3. 4. 5. Noted by:
Noted by:
Zenaida Torrente, RN, MAN Ligaya Paragas, BSN, RN, MAN D. Pielago, RN, MAN Signature and Printed Name of Clinical Coordinator Name of Chief Nurse Signature Over Printed Name of Dean
Noted by: Evelyn Rubia, RN, MAN, PhD Signature and Printed Name of Chief Nurse
Approved by: Dean Vizsabelle Signature Over Printed
Date Signed : Date Signed : Date Signed : Date Signed : Degree : Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Arts in Nursing Arts in Nursing Arts in Nursing Arts in Nursing a) PRC No. : 0053516 a) PRC No. : 0129700 a) PRC No. : 0098006 a) PRC No. : 0075654
Valid until : January 3, 2011 : January 2011 b) PNA No. : 17874 Valid until until
Valid until b) PNA No.
: lifetime : December 2009
: July 6, 2010
Valid until
: 009221
Valid until
b) PNA No.
: December 2009
: October 22, 2011 : 7845
Valid until
Valid until b) PNA No.
: Lifetime
Valid
c) ADCPN No. Valid until PREPARED BY:
: 004404
: 0411 : December 2009
_________________________ Signature over Name of Student
Name of Student Name and Address of School ________
: __________________ : ___________________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
First Course (if any) School Graduated From
_______
______________________________________ : __________________ : ___________________
: :
Year of Admission in the BSN Program : Year Graduated from the BSN Program :
Year: ________________
IV. Deliveries Assisted No .
Case No.
Diagnosis
Name of Patient
Age
Date of Deliver y
Time of Delivery
Gender of Baby
Name of Hospital
Type of Delivery
Supervised by: Name and Signature of Qualified C. I.
1. 2. 3. 4. 5. Noted by:
Noted by:
Zenaida Torrente, RN, MAN Ligaya Paragas, BSN, RN, MAN D. Pielago, RN, MAN Signature and Printed Name of Clinical Coordinator Name of Chief Nurse Signature Over Printed Name of Dean
Noted by: Evelyn Rubia, RN, MAN, PhD Signature and Printed Name of Chief Nurse
Approved by: Dean Vizsabelle Signature Over Printed
Date Signed : Date Signed : Date Signed : Date Signed : Degree : Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Arts in Nursing Arts in Nursing Arts in Nursing Arts in Nursing a) PRC No. : 0053516 a) PRC No. : 0129700 a) PRC No. : 0098006 a) PRC No. : 0075654 Valid until : January 3, 2011 Valid until : July 6, 2010 Valid until : October 22, 2011 Valid until : January 2011 b) PNA No. : 17874 b) PNA No. : 009221 b) PNA No. : 7845 b) PNA No. : 004404 Valid until until
: lifetime : December 2009
Valid until
: December 2009
Valid until
: Lifetime
Valid
c) ADCPN No. Valid until PREPARED BY:
: 0411 : December 2009
________________________ Signature over Name of Student
Name of Student Name and Address of School ________________
: _________________ : ____________________________
Recognition and Accreditation Level (if any) Date School/ Program Recognized
First Course (if any) School Graduated From
_______
___________________________________ : __________ : ___________________
: :
Year of Admission in the BSN Program : Year Graduated from the BSN Program :
Year: ________________
V. Cord Dressings No . 1. 2.
Case No.
Date Performed
Name of Baby
Gender of baby
Name of Mother
Age
Name of Hospital
Supervised by: Name and Signature of Qualified C. I.
3. 4. 5. Noted by:
Noted by:
Noted by:
Zenaida Torrente, RN, MAN Ligaya Paragas, BSN, RN, MAN D. Pielago, RN, MAN Signature and Printed Name of Clinical Coordinator Name of Chief Nurse Signature Over Printed Name of Dean
Approved by:
Evelyn Rubia, RN, MAN, PhD Signature and Printed Name of Chief Nurse
Dean Vizsabelle Signature Over Printed
Date Signed : Date Signed : Date Signed : Date Signed : Degree : Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing, Degree :Bachelor of Science in Nursing Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Registered Nurse, Master of Arts in Nursing Arts in Nursing Arts in Nursing Arts in Nursing a) PRC No. : 0053516 a) PRC No. : 0129700 a) PRC No. : 0098006 a) PRC No. : 0075654 Valid until : January 3, 2011 Valid until : July 6, 2010 Valid until : October 22, 2011 Valid until : January 2011 b) PNA No. : 17874 b) PNA No. : 009221 b) PNA No. : 7845 b) PNA No. : 004404 Valid until until
: lifetime : December 2009
Valid until
: December 2009
Valid until
: Lifetime c) ADCPN No. Valid until
PREPARED BY:
_________________________ Signature over Name of Student
Valid : 0411 : December 2009
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