Prc-bon Memorandum Order No. 2-b Series Of 2009
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ODC Form 2A O.R. SCRUB FORM Major
SCHOOL LOGO
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 Prepared by: Printed Name with Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS (only) Case Number
SURGICAL PROCEDURE PERFORMED
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
O.R. Nurse On Duty (Name AND Signature)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
ODC Form 2B O.R. MINOR FORM
SCHOOL LOGO
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
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS Only Case Number
SURGICAL PROCEDURE PERFORMED
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
ODC Form 1A SCHOOL
ACTUAL DELIVERY FORM
LOGO 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 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)
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
SCHOOL ODC Form 1B ASSISTED DELIVERY
LOGO
FORM
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 Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIAL Only Case Number (not applicable for Birthing/LyingIn Clinics/Homes)
PROCEDURE PERFORMED ASSISTED DELIVERY
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
ODC Form 1C
SCHOOL
CORD CARE FORM
LOGO 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) IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province 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
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
SCHOOL LOGO
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 Prepared by: Printed Name with Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS (only) Case Number
SURGICAL PROCEDURE PERFORMED
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
O.R. Nurse On Duty (Name AND Signature)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
ODC Form 2B O.R. MINOR FORM
SCHOOL LOGO
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
Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIALS Only Case Number
SURGICAL PROCEDURE PERFORMED
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
ODC Form 1A SCHOOL
ACTUAL DELIVERY FORM
LOGO 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 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)
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
SCHOOL ODC Form 1B ASSISTED DELIVERY
LOGO
FORM
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 Prepared by: Printed Name and Signature of Student ______________________________________________ Date Performed and Time Started
Patient’s INITIAL Only Case Number (not applicable for Birthing/LyingIn Clinics/Homes)
PROCEDURE PERFORMED ASSISTED DELIVERY
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
ODC Form 1C
SCHOOL
CORD CARE FORM
LOGO 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) IMMEDIATE NEWBORN CORD CARE in ________________________________________________________________________ Hospital/Home/Lying-In Clinic, Municipality/City/Province 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
Noted by: _______________________________________________ (Print Name and Signature) Clinical Coordinator, PRC I.D No. ________________ Valid Until ____________ Date document is signed: _________________________ Time __________________ Please specify Highest Nursing Degree Earned: _______________________________
Nurse On Duty (Name and Signature) (If Midwife on Duty, signature not required)
SUPERVISED BY Clinical Instructor Name and Signature
Approved by: ___________________________________________________ (Print Name and Signature) Dean, PRC I.D. No. ____________________ Valid Until __________________________ Date document is signed: ______________________ Time: _______________________ Specify Highest Nursing Degree Earned: ______________________________________
(STRICTLY NO DESIGNATES)
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