Format Update 2.0 University Of Pangasinan Minor Operations

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING DAGUPAN CITY NAME OF STUDENT: Name and Address of School:

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

University Seal

First Course (if any): School graduated from: Year: Year of admission in the BSN Program: June 2007 Year graduated from BSN Program: 2010 II. MINOR OPERATIONS REMOVE “S” IF ONLY CONTAINS 1 CASE

No.

1

DATE of OPERATION

TIME OF OPERATION STARTEDENDED

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1-9 Never Put 0 Just type 8:00 AM/PM

2

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3

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4

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NAME OF PATIENT

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CASE NO.

No abbreviations

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OPERATION PERFORMED

DIAGNOSIS

No abbreviations

TYPE of NAME of NAME of Name and Signature of Qualified ANESTHESIA SURGEON HOSPITAL Clinical Instructor Local, Regional, General, Intravenous Sedation

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Remove if unfilled Remove if unfilled 5 LEGEND: HOSPITAL’S ACRONYM = Hospital’s Complete Name (Level) [Bold Letters Here]

Dr.

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Prepared by:

ALLCAPS HOSPITAL ACRONYM Remove if unfilled

I-AM D. CI, RN

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Concurred by: PAUL CHRISTIAN P. SANTOS Student

_____,Chief Nurse Date Signed: Degree: a). PRC No.: b). PNA No.: c). ANSAP No.:

Supervised by:

Noted by:

Valid Until: Valid Until:

Date Signed: Degree: a). PRC No.: b). PNA No.: c). ANSAP No.:

Valid Until: Valid Until: Valid Until:

Approved by: ZENAIDA M. BAUTISTA Clinical Coordinator

Clinical Instructor Date Signed: Degree: a). PRC No.: b). PNA No.:

[PUT “MRS.” IF Female and Married]

Remove if unfilled AND ENLARGE THE UPang LOGO [3-5 CASES logo size = 1Peso Coin] [1-2 CASES logo size = 5Peso Coin] and consume the SPACE

BSN-RN, MAN 0133422 Valid Until: July 27, 2011 029069 Valid Until: December 31, 2009 09-0054 Valid Until: December 31, 2009

MELANIA C. CENON Dean Date Signed: Degree: a). PRC No.: b). PNA No.: c). ADPCN No.:

BSN-RN, MAN, MAEd, PhD 0100236 Valid Until: January 06, 2012 17978 Valid Until: Lifetime Member 0185 Valid Until: December 31, 2009

RED INKS ARE THE GUIDES IN FILLING YOUR CASES DELETE IT BEFORE PRINTING