Case Loads
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EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
ACTUAL DELIVERY in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name
Signature of Student: _________________
PROCEDURE PERFORMED
D.R. Nurse/Midwife On Duty
Case Number
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
ASSISTED DELIVERY in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name Case Number
PROCEDURE PERFORMED
Signature of Student: _________________ D.R. Nurse/Midwife On Duty
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite
Time: ________
046-4164340, 046-4164341
IMMEDIATE NEWBORN CORD CARE in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name
Signature of Student: _________________
PROCEDURE PERFORMED
D.R. Nurse/Midwife On Duty
Case Number
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
Time: ________
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
SURGICAL MINOR SCRUB in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name Case Number
PROCEDURE PERFORMED
Signature of Student: _________________ O.R. Nurse On Duty
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
SURGICAL MAJOR SCRUB in ________________________________________ Hospital, Municipality/City/Province
Time: ________
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name
Signature of Student: _________________
PROCEDURE PERFORMED
O.R. Nurse On Duty
Case Number
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
Time: ________
ACTUAL DELIVERY in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name
Signature of Student: _________________
PROCEDURE PERFORMED
D.R. Nurse/Midwife On Duty
Case Number
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
ASSISTED DELIVERY in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name Case Number
PROCEDURE PERFORMED
Signature of Student: _________________ D.R. Nurse/Midwife On Duty
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite
Time: ________
046-4164340, 046-4164341
IMMEDIATE NEWBORN CORD CARE in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name
Signature of Student: _________________
PROCEDURE PERFORMED
D.R. Nurse/Midwife On Duty
Case Number
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
Time: ________
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
SURGICAL MINOR SCRUB in ________________________________________ Hospital, Municipality/City/Province
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name Case Number
PROCEDURE PERFORMED
Signature of Student: _________________ O.R. Nurse On Duty
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
EMILIO AGUINALDO COLLEGE School of Nursing and Midwifery Congressional Road Burol Main, Dasmariñas, Cavite 046-4164340, 046-4164341
SURGICAL MAJOR SCRUB in ________________________________________ Hospital, Municipality/City/Province
Time: ________
Prepared by: Name of Student:
___________________________________________
Date Performed and Time Started
Patient’s Name
Signature of Student: _________________
PROCEDURE PERFORMED
O.R. Nurse On Duty
Case Number
SUPERVISED BY Clinical Instructor Name and Signature
Noted by:
Concurred by:
Approved by:
Signature over printed Name of Chief Nurse
Signature over printed Name of Clinical Coordinator
Signature by the Dean of the College
Date Signed: ___________
Date Signed: ___________
Date Signed: ___________
Time: ________
Time: ________
Degree:
Degree:
Degree:
PRC License:
PRC License:
PRC License:
Valid Until:
Valid Until:
Valid Until:
PNA No.:
PNA No.:
PNA No.:
Valid Until:
Valid Until:
Valid Until: ADPCN No.: Valid Until:
Time: ________
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