Prc-bon Memorandum Order No. 1-b Series Of 2009
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NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) SURGICAL SCRUB in ________________________________________________________________________ Hospital, Municipality/City/Province
O.R. Form 1A Prepared by: Printed Name with Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS (only) Case Number
SURGICAL PROCEDURE PERFORMED
O.R. SCRUB FORM Major
O.R. Nurse On Duty (Name AND Signature)
O,R, Form 1B
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS Only Case Number
SURGICAL PROCEDURE PERFORMED
SUPERVISED BY Clinical Instructor Name and Signature
O.R. CICRUCLATING FORM
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]
NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) ACTUAL DELIVERY in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province
D.R. Form
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIAL Only Case Number
PROCEDURE PERFORMED
(not applicable for Birthing/LyingIn Clinics/Homes)
ACTUAL DELIVERY FORM
D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor Name and Signature
IMMEDIATE NEWBORN CORD CARE in _______________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province
ICNB Form
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIAL Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/Homes)
Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home
IMMEDIATE CARE OF THE NEWBORN FORM
Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)
SUPERVISED BY Clinical Instructor Name and Signature
(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]
O.R. Form 1A Prepared by: Printed Name with Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS (only) Case Number
SURGICAL PROCEDURE PERFORMED
O.R. SCRUB FORM Major
O.R. Nurse On Duty (Name AND Signature)
O,R, Form 1B
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS Only Case Number
SURGICAL PROCEDURE PERFORMED
SUPERVISED BY Clinical Instructor Name and Signature
O.R. CICRUCLATING FORM
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]
NAME OF SCHOOL COMPLETE BUSINESS ADDRESS PHONE NUMBER/S, Fax Number/s, E-Mail Address, Web-Site (If ACCREDITED: BY WHOM AND WHAT LEVEL, Inclusive Date of Accreditation) ACTUAL DELIVERY in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province
D.R. Form
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIAL Only Case Number
PROCEDURE PERFORMED
(not applicable for Birthing/LyingIn Clinics/Homes)
ACTUAL DELIVERY FORM
D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor Name and Signature
IMMEDIATE NEWBORN CORD CARE in _______________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province
ICNB Form
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIAL Only Case Number (not applicable for Birthing Homes/Lying-In Clinics/Homes)
Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home
IMMEDIATE CARE OF THE NEWBORN FORM
Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)
SUPERVISED BY Clinical Instructor Name and Signature
(STRICTLY NO DESIGNATES) [These Forms must be printed at the back of the 1st page of the Competency-Based Performance Evaluation Checklist prescribed by the BoN]
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