ODC Form 1A ACTUAL DELIVERY FORM

Our Lady of Fatima University Esperanza St., Hilltop Mansion, Lagro, Quezon City ACTUAL DELIVERY in CONGRESSMAN ROGACIANO MERCADO MEMORIAL HOSPITAL Hospital,Municipality/City/Province Prepared by: Printed Name and Signature of Student RAGO, ARLHON JANE MENA

Date Performed And Time Started

Patients INITIAL Only ______________________ Case Number

(not applicable for Birthing/Lying-In Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not required)

SUPERVISED BY Clinical Instructor Name and Signature

July 21, 2011 12:40 AM July 22, 2011 1:35 AM July 22, 2012 7:21 AM
Noted by:

G.O 012011-34650 I.D. 012011-30723 S.N. 012011-8454

Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

ROSSANA PEREZ, RN ROSSANA PEREZ, RN ROSSANA PEREZ, RN

Approved by:

JACQUELYN JOYCE G. GALLER RN, MAN JACQUELYN JOYCE G. GALLER RN, MAN JACQUELYN JOYCE G. GALLER RN, MAN

LIZA MAY B. JECINO RN, MAN _ Clinical Coordinator PRC I.D. No.: 164056 Valid Until: January 25, 2013 PNA I.D. No.: 2011-17397 Valid Until: Lifetime

NELIA R. CAPULONG RN, RM, MAN PRC I.D. No.: 041250 PNA I.D. No.: 19849 Dean Valid Until: February 2013 Valid Until: Lifetime

_ PRC I.D. No.: 0041904 Valid Until: July 31, 2012 PNA I.D. No.: 18698 Valid Until: Lifetime

PRC I.D. No.: 0111345 Valid Until: September 3, 2014 PNA I.D. No.: 2012-022342 Valid Until: December 2012

Date document is signed: ______ Time: ____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: ____ Time: ___ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

ODC Form 1B ASSISTED DELIVERY FORM

Our Lady of Fatima University Esperanza St., Hilltop Mansion, Lagro, Quezon City ASSISTED DELIVERY in CONGRESSMAN ROGACIANO MERCADO MEMORIAL HOSPITAL/ FATIMA UNIVERSITY MEDICAL CENTER Hospital,Municipality/City/Province Prepared by: Printed Name and Signature of Student RAGO, ARLHON JANE MENA

Date Performed And Time Started

Patients INITIAL Only ______________________ Case Number

(not applicable for Birthing/LyingIn Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not required)

SUPERVISED BY Clinical Instructor Name and Signature

July 21, 2011 4:16 PM July 22, 2011 3:45 AM January 29, 2011 5:50 AM
Noted by:

G.D. 012011-33043 A.B. 012011-34893 R.C. 2012-002199

Concurred by:

Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

ROSSANA PEREZ, RN ROSSANA PEREZ, RN NELIA TROPICALES, RN

Concurred by:

JACQUELYN JOYCE G. GALLER RN, MAN JACQUELYN JOYCE G. GALLER RN, MAN GINA M. ROCKWELL, RN
Approved by: NELIA R. CAPULONG RN, RM, MAN _ Dean PRC I.D. No.: 0041904 Valid Until: July 31, 2012 PNA I.D. No.: 18698 Valid Until: Lifetime

LIZA MAY B. JECINO RN, MAN _ Clinical Coordinator PRC I.D. No.: 164056 Valid Until: January 25, 2013 PNA I.D. No.: 2011-17397 Valid Until: Lifetime

ESTELITA B. LORENZO RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 0111345 Valid Until: September 3, 2014 PNA I.D. No.: 2012-022342 Valid Until: December 2012

CATALINA M. HALILI RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 041250 Valid Until: February 2013 PNA I.D. No.: 19849 Valid Until: Lifetime

Date document is signed: ______ Time: ____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: ____ Time: ___ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

ODC Form 1C CORD CARE FORM

Our Lady of Fatima University Esperanza St., Hilltop Mansion, Lagro, Quezon City IMMEDIATE NEWBORN CORD CARE in CONGRESSMAN ROGACIANO MERCADO MEMORIAL HOSPITAL/ FATIMA UNIVERSITY MEDICAL CENTER Hospital,Municipality/City/Province Prepared by: Printed Name and Signature of Student RAGO, ARLHON JANE MENA

Date Performed And Time Started

Patients 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 Cord Dressing Room Cord Dressing Room Cord Dressing Room

Nurse On Duty (Name and Signature) (If Midwife on Duty, Signature not required)

SUPERVISED BY Clinical Instructor Name and Signature

July 21,2011 6:40 AM July 22, 2011 11:07 PM January 21 ,2012 7:10 AM
Noted by:

G.D. 012011-29360 A.B. 012011-306505 2012-070892

Concurred by:

ROSSANA PEREZ, RN ROSSANA PEREZ, RN LEONORA B. ONOFRE, RM, RN

Concurred by:

JACQUELYN JOYCE G. GALLER RN, MAN JACQUELYN JOYCE G. GALLER RN, MAN NORBERTA C. ALCARION, RN, RM, MAN
Approved by: NELIA R. CAPULONG RN, RM, MAN _ Dean PRC I.D. No.: 0041904 Valid Until: July 31, 2012 PNA I.D. No.: 18698 Valid Until: Lifetime

LIZA MAY B. JECINO RN, MAN _ Clinical Coordinator PRC I.D. No.: 164056 Valid Until: January 25, 2013 PNA I.D. No.: 2011-17397 Valid Until: Lifetime

CATALINA M. HALILI RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 041250 Valid Until: February 2013 PNA I.D. No.: 19849 Valid Until: Lifetime

ESTELITA B. LORENZO RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 0111345 Valid Until: September 3, 2014 PNA I.D. No.: 2012-022342 Valid Until: December 2012

Date document is signed: ______ Time: ____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: ____ Time: ___ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Our Lady of Fatima University Esperanza St., Hilltop Mansion, Lagro, Quezon City SURGICAL SCRUB in FATIMA UNIVERSITY MEDICAL CENTER Hospital,Municipality/City/Province Prepared by: Printed Name and Signature of Student RAGO, ARLHON JANE MENA

ODC Form 2A O.R. SCRUB FORM Major

Date Performed And Time Started

Patients INITIALS (only) ______________________ Case Number

SURGICAL PROCEDURE PERFORMED

Amputation 5TH Digit Right Foot Cholelithiasis TABSHO
Concurred by:

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

December 19, 2011 12:35 PM December 09, 2011 04:26 PM March 14, 2012 09:00 AM

M.P.A. 2011-062339 A.S.M. 2011-024386 F.A. 267901

Concurred by:

GABRIEL F. NAIG RN, MAN GABRIEL F. NAIG RN, MAN GABRIEL F. NAIG RN, MAN

SECINIA I. TALLO, RM, RN, MAN SECINIA I. TALLO RM, RN, MAN SECINIA I. TALLO RM, RN, MAN
Approved by: NELIA R. CAPULONG RN, RM, MAN _ Dean PRC I.D. No.: 0041904 Valid Until: July 31, 2012 PNA I.D. No.: 18698Valid Until: : Lifetime

Noted by: LIZA MAY B. JECINO RN, MAN _ Clinical Coordinator PRC I.D. No.: 164056 Valid Until: January 25, 2013 PNA I.D. No.: 2011-17397 Valid Until: Lifetime

ESTELITA B. LORENZO RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 0111345 Valid Until: September 3,2014 PNA I.D. No.: 2012-022342 Valid Until: December 2012

ELSA N. PACHECO RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 0125729 Valid Until: October 13, 2014 PNA I.D. No.: 2012-032088 Valid Until: October 2012

Date document is signed: ______ Time: ____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: ____ Time: ___ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Our Lady of Fatima University Esperanza St., Hilltop Mansion, Lagro, Quezon City CIRCULATING in ATIMA UNIVERSITY MEDICAL CENTER Hospital, Municipality/City/Province Prepared by: Printed Name and Signature of Student RAMIRO, EILEEN MAE TEODOSIO

ODC Form 2B O.R. CIRCULATING FORM

Date Performed And Time Started September 15, 2011 05:30 PM December 19, 2011 12:35 PM

Patients INITIALS Only ______________________ Case Number C.M.L. 2011-06449 J.E.D. 2011-070336 R.C. 287387
Concurred by:

SURGICAL PROCEDURE PERFORMED

Emergency Ceasarean section

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

GABRIEL F. NAIG RN, MAN Pars Plana Vitrectomy Phaco Fragmentation, Left Eye Appendectomy
Concurred by: ELSA N. PACHECO RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 0125729 Valid Until: October 13, 2014 PNA I.D. No.: 2012-032088 Valid Until: October 2012

SECINIA I. TALLO, RM, RN, MAN SECINIA I. TALLO, RM, RN, MAN

GABRIEL F. NAIG RN, MAN

March 14, 2012 1:50 PM

GIL Y. DIAZ, RN, MAN

Approved by: NELIA R. CAPULONG RN, RM, MAN _ Dean PRC I.D. No.: 0041904 Valid Until: July 31, 2012 PNA I.D. No.: 18698 Valid Until: : Lifetime

Noted by: LIZA MAY B. JECINO RN, MAN _ Clinical Coordinator PRC I.D. No.: 164056 Valid Until: January 25, 2013 PNA I.D. No.: 2011-17397 Valid Until: Lifetime

ESTELITA B. LORENZO RN, MAN _ Chief Nurse of the Hospital PRC I.D. No.: 0111345 Valid Until: September 3, 2014 PNA I.D. No.: 2012-022342 Valid Until: December 2012

Date document is signed: ______ Time: ____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: _____ Time: _____ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing

Date document is signed: ____ Time: ___ Please specify Highest Nursing Degree Earned: Master of Arts in Nursing