Case Format Ii Minor Operations

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING Dagupan City NAME OF STUDENT: Name and Address of School:

University Seal

First Course: School Graduated from: Year: __________________________________ Year of Admission in the BSN Program: Year Graduated from BSN Program:

University of Pangasinan Arellano St., Dagupan City Accreditation Level (if any): Level I (PACUCOA) Year Granted: March 05, 2007 Date of School/Program was recognized: May 19, 1976 Number: 44 Year: 1976

II. MINOR OPERATIONS No.

DATE of OPERATIONS

TIME OF OPERATION STARTEDENDED

NAME OF PATIENT CASE NO.

DIAGNOSIS

OPERATION PERFORMED

TYPE of ANESTHESIA

NAME of SURGEON

NAME of HOSPITAL

Name and Signature of Qualified Clinical Instructor

1 2 3 4 5 LEGEND: Concurred by: Prepared by: __ Date Signed: Degree: a.) PRC No. b.) PNA No. c.) ANSAP No.

Student

Supervised by:

Noted by: Clinical Instructor

Date Signed: ____________________________________________________ Degree: a.) PRC No. Valid Until: b.) PNA No. Valid Until:

___, Chief Nurse Valid Until: Valid Until: Valid Until:

Approved by: ZENAIDA M. BAUTISTA Clinical Coordinator

Date Signed: _____________________________________________________ Degree: BSN-RN,MAN a.) PRC No. 0133422 _____ Valid Until: July 27, 2010 b.) PNA No. 029069 Valid Until: December 31, 209 c.) ANSAP No. 09-0054 Valid Until: December 31, 2009

DR. MELANIA C. CENON Dean Date Signed: _____ Degree: ________BSN-RN,MAN,MaEd,PhD____________________________ a.) PRC No. 100236 Valid Until: January 6, 2012 b.) PNA No. 17978 Valid Until: Lifetime Member c.) ADPCN No. 0185 Valid Until: December 31, 2009