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UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 1C CORD CARE FORM
IMMEDIATE NEWBORN CORD CARE in _____________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
Case Number (not applicable for Birthing Home/ Lying-in Clinics/ Names)
IMMEDIATE NEWBORN CORD CARE PERFORMED (Indicate where performed e.g. D.R., Nursery, or Home)
O.R. Nurse On Duty (Name and Signature) (If midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 1B ASSISTED DELIVERY FORM
ACTUAL DELIVERY in _____________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
Case Number (not applicable for Birthing Home/ Lying-in Clinics/ Names)
PROCEDURE PERFORMED
D.R. Nurse On Duty (Name and Signature)
ASSISTED DELIVERY
(If midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 1A ACTUAL DELIVERY FORM
ACTUAL DELIVERY in _____________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
D.R. Nurse On Duty (Name and Signature)
Case Number (not applicable for Birthing Home/ Lying-in Clinics/ Names)
PROCEDURE PERFORMED
(If midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 2B OR MINOR FORM
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
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 2A O.R. SCRUB FORM MAJOR
SURGICAL SCRUB in _____________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
Case Number
SURGICAL PROCEDURE PERFORMED
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
ODC Form 1C CORD CARE FORM
IMMEDIATE NEWBORN CORD CARE in _____________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
Case Number (not applicable for Birthing Home/ Lying-in Clinics/ Names)
IMMEDIATE NEWBORN CORD CARE PERFORMED (Indicate where performed e.g. D.R., Nursery, or Home)
O.R. Nurse On Duty (Name and Signature) (If midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 1B ASSISTED DELIVERY FORM
ACTUAL DELIVERY in _____________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
Case Number (not applicable for Birthing Home/ Lying-in Clinics/ Names)
PROCEDURE PERFORMED
D.R. Nurse On Duty (Name and Signature)
ASSISTED DELIVERY
(If midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 1A ACTUAL DELIVERY FORM
ACTUAL DELIVERY in _____________________________________________________ Hospital/Home/Lying-in Clinic, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
D.R. Nurse On Duty (Name and Signature)
Case Number (not applicable for Birthing Home/ Lying-in Clinics/ Names)
PROCEDURE PERFORMED
(If midwife on Duty, Signature Not Required)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 2B OR MINOR FORM
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
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES PHONE: 032 3433005; FAX: 032 3433006; [email protected]; www.usc.edu.ph PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011
ODC Form 2A O.R. SCRUB FORM MAJOR
SURGICAL SCRUB in _____________________________________________________ Hospital, Municipality/City/Province Prepared by: Printed Name with Signature of Student: ____________________________________
Patient’s INITIALS (only) Date Performed and Time Started
Case Number
SURGICAL PROCEDURE PERFORMED
O.R. Nurse On Duty (Name and Signature)
SUPERVISED BY Clinical Instructor (Name and Signature)
Noted by: __________________________________________________________ (Print Name and Signature)
Approved by: _______________________________________________
Clinical Coordinator, PRC I.D. No. _____________________Valid Until_____________
DEAN, PRC I.D. No. ____________________ Valid Until ______________
Date document is signed ___________________________ Time_________________
Date document is signed_________________ Time___________________
Please Specify Highest Nursing Degree Earned_________________________________
Specify Highest Nursing Degree Earned_____________________________
(Print Name and Signature)
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