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PROFESSIONAL REGULATION COMMISSION Manila BOARD OF MIDWIFERY Record of Actual Suturing of Perineal Lacerations Please Check If applicant is: / Name of Applicant: ZABRINAH JEAN LIM USOP
Name and Address of Patient
1.MARIA FE CAYETANO IRAWAN,PUER TO PRINCESA CITY, PALAWAN
2.JAYVIE FRANCISCO JOLO ROXAS, PALAWAN
Graduate Midwife
Registered Nurse
School: PALAWAN STATE UNIVERSITY
Supervised By: Case No.
365192
585670
Complete Diagnosis (Garvida_Para_)
G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 3200 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 3200 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia
Date & Time Performed
Check Full Name, If Home Address of Del. Faculty & Contact Number
OSPITAL NG PALAWAN 02-21-2018 Malvar Street, 05:10 pm Puerto Princesa City Palawan TEL NO.(048) 433-2621
OSPITAL NG PALAWAN 02-27-2018 Malvar Street, 07:52 pm Puerto Princesa City Palawan TEL NO.(048) 433-2621
Printed Name & Contact No.
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
Position/ Designation
Signature
License No./Exp. Date
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
0132355 06-13-2019
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
0132355 06-13-2019
Name and Address of Patient
3.MELANIE ALFORQUE TINITIAN, ROXAS, PALAWAN
4. SHERLYN JOY EBO MATAHIMIK,P UERTO PRINCESA CITY
5. MARIA AZENITH DADAYA TINIGUIBAN,P UERTO PRINCESA CITY, PALAWAN
Case No.
106181
382125
263420
Complete Diagnosis (Garvida_Para_)
G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 2783 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 2790 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age. 2820 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia
Date & Time Performed
Check Full Name, If Home Address of Del. Faculty & Contact Number
OSPITAL NG PALAWAN Malvar Street, 03-15-2018 Puerto Princesa 07:30 am City Palawan TEL NO.(048) 433-2621
Printed Name & Contact No.
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
OSPITAL NG PALAWAN Malvar Street, Puerto Princesa 03-20-2018 City Palawan 04:45 pm TEL NO.(048) 433-2621
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
OSPITAL NG PALAWAN Malvar Street, Puerto Princesa City Palawan TEL NO.(048) 433-2621
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
03-222018 08:13 am
Supervised By: Position/ Designation Signature
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
License No./Exp. Date
0132355 06-13-2019
0132355 06-13-2019
0132355 06-13-2019
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor. 2.) Registered Midwives/ Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on Suturing of Perineal Lacerations to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/ clinical instructor. SUBSCRIBE AND SWORN T before me this ___________________________ at ___________________ Affiant exhibiting to me his/her Residence Certificate No. ______________ issued at _______________________ on _______________.
Affix Administering Officer or Notary Public
Documentary Stamp (To be posted on the last page)
(
CERTIFIED CORRECT: Signature: ____________________ Date: ___________ Printed Name:JOJI C. MARTAL,RM,BCHS,MMHA,ND Designation: REGISTERED MIDWIFE/CLINICALINSTRUCTOR Lic. No.: 0042106 Expiry Date: 05-20-2019
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor. 2.) Registered Midwives/ Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on Intravenous Insertion to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/ clinical instructor. SUBSCRIBE AND SWORN T before me this ___________________________ at ___________________ Affiant exhibiting to me his/her Residence Certificate No. ______________ issued at _______________________ on _______________.
Affix Administering Officer or Notary Public
Documentary Stamp (To be posted on the last page)
(
CERTIFIED CORRECT: Signature: ____________________ Date: ___________ Printed Name:JOJI C. MARTAL,RM,BCHS,MMHA,ND Designation: REGISTERED MIDWIFE/CLINICALINSTRUCTOR Lic. No.: 0042106 Expiry Date: 05-20-2019
Name and Address of Patient
1.MARIA FE CAYETANO IRAWAN,PUER TO PRINCESA CITY, PALAWAN
2.JAYVIE FRANCISCO JOLO ROXAS, PALAWAN
Graduate Midwife
Registered Nurse
School: PALAWAN STATE UNIVERSITY
Supervised By: Case No.
365192
585670
Complete Diagnosis (Garvida_Para_)
G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 3200 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 3200 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia
Date & Time Performed
Check Full Name, If Home Address of Del. Faculty & Contact Number
OSPITAL NG PALAWAN 02-21-2018 Malvar Street, 05:10 pm Puerto Princesa City Palawan TEL NO.(048) 433-2621
OSPITAL NG PALAWAN 02-27-2018 Malvar Street, 07:52 pm Puerto Princesa City Palawan TEL NO.(048) 433-2621
Printed Name & Contact No.
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
Position/ Designation
Signature
License No./Exp. Date
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
0132355 06-13-2019
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
0132355 06-13-2019
Name and Address of Patient
3.MELANIE ALFORQUE TINITIAN, ROXAS, PALAWAN
4. SHERLYN JOY EBO MATAHIMIK,P UERTO PRINCESA CITY
5. MARIA AZENITH DADAYA TINIGUIBAN,P UERTO PRINCESA CITY, PALAWAN
Case No.
106181
382125
263420
Complete Diagnosis (Garvida_Para_)
G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 2783 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age 2790 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia G1P1(1001)Pregnancy Uterine, Delivered Term,Cephalic,To Live Baby Girl As of 8,9 Appropriate For Gestational Age. 2820 By Normal Spontaneous Delivery 1st Degree Laceration Repaired Via Local Anesthesia
Date & Time Performed
Check Full Name, If Home Address of Del. Faculty & Contact Number
OSPITAL NG PALAWAN Malvar Street, 03-15-2018 Puerto Princesa 07:30 am City Palawan TEL NO.(048) 433-2621
Printed Name & Contact No.
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
OSPITAL NG PALAWAN Malvar Street, Puerto Princesa 03-20-2018 City Palawan 04:45 pm TEL NO.(048) 433-2621
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
OSPITAL NG PALAWAN Malvar Street, Puerto Princesa City Palawan TEL NO.(048) 433-2621
MARICHELLE V.DELOS SANTOS,RN,MAN, ND 09355304531
03-222018 08:13 am
Supervised By: Position/ Designation Signature
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
REGISTERED MIDWIFE/CLI NICAL INSTRUCTOR
License No./Exp. Date
0132355 06-13-2019
0132355 06-13-2019
0132355 06-13-2019
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor. 2.) Registered Midwives/ Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on Suturing of Perineal Lacerations to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/ clinical instructor. SUBSCRIBE AND SWORN T before me this ___________________________ at ___________________ Affiant exhibiting to me his/her Residence Certificate No. ______________ issued at _______________________ on _______________.
Affix Administering Officer or Notary Public
Documentary Stamp (To be posted on the last page)
(
CERTIFIED CORRECT: Signature: ____________________ Date: ___________ Printed Name:JOJI C. MARTAL,RM,BCHS,MMHA,ND Designation: REGISTERED MIDWIFE/CLINICALINSTRUCTOR Lic. No.: 0042106 Expiry Date: 05-20-2019
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/clinical instructor. 2.) Registered Midwives/ Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on Intravenous Insertion to the Board pursuant to Board Resolution No. 100, Series of 1993, dated December 1, 1993.
NOTE: 1.) For graduate midwives: Supervision must be by qualified faculty/ clinical instructor. SUBSCRIBE AND SWORN T before me this ___________________________ at ___________________ Affiant exhibiting to me his/her Residence Certificate No. ______________ issued at _______________________ on _______________.
Affix Administering Officer or Notary Public
Documentary Stamp (To be posted on the last page)
(
CERTIFIED CORRECT: Signature: ____________________ Date: ___________ Printed Name:JOJI C. MARTAL,RM,BCHS,MMHA,ND Designation: REGISTERED MIDWIFE/CLINICALINSTRUCTOR Lic. No.: 0042106 Expiry Date: 05-20-2019
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