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    PRC Official Form

    Uploaded by

    Nayda Condez-Casim
    The document contains forms from Far Eastern University for students to document their clinical experiences, including major surgical scrub, minor surgical scrub, actual delivery, and immediate newborn care. The forms require students to provide information such as the date, time, patient initials, procedure, case number, supervising nurse and clinical instructor. Clinical coordinators, chief nurses, and the Dean of the university are responsible for noting, concurring with, and approving the clinical experiences.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    PRC Official Form

    Uploaded by

    Nayda Condez-Casim
    118 views4 pages
    The document contains forms from Far Eastern University for students to document their clinical experiences, including major surgical scrub, minor surgical scrub, actual delivery, and immediate newborn care. The forms require students to provide information such as the date, time, patient initials, procedure, case number, supervising nurse and clinical instructor. Clinical coordinators, chief nurses, and the Dean of the university are responsible for noting, concurring with, and approving the clinical experiences.

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    The document contains forms from Far Eastern University for students to document their clinical experiences, including major surgical scrub, minor surgical scrub, actual delivery, and immediate newborn care. The forms require students to provide information such as the date, time, patient initials, procedure, case number, supervising nurse and clinical instructor. Clinical coordinators, chief nurses, and the Dean of the university are responsible for noting, concurring with, and approving the clinical experiences.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    118 views4 pages

    PRC Official Form

    Uploaded by

    Nayda Condez-Casim
    The document contains forms from Far Eastern University for students to document their clinical experiences, including major surgical scrub, minor surgical scrub, actual delivery, and immediate newborn care. The forms require students to provide information such as the date, time, patient initials, procedure, case number, supervising nurse and clinical instructor. Clinical coordinators, chief nurses, and the Dean of the university are responsible for noting, concurring with, and approving the clinical experiences.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
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    FAR EASTERN UNIVERSITY

    Nicanor Reyes Sr. Street Sampaloc Manila 1008


    Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
    PAASCU, Level II Re-Accredited, May 2011
    MAJOR SURGICAL SCRUB in _________________________________________________________________
    Hospital, Municipality/City/Province
    Prepared by:
    Printed Name with Signature of Student _________________________________________
    Date Performed
    and
    Time Started

    Patients INITIALS (only)


    SURGICAL PROCEDURE
    PERFORMED

    Case Number

    O.R. Nurse on Duty


    (Name and Signature)

    SUPERVISED BY
    Clinical Instructor
    (Name and Signature)

    Noted by:

    Concurred by:

    Approved by:

    MONICA C. LAGONOY - AONUEVO, RN, MAN__


    Signature over printed name of Clinical Coordinator
    Date signed:
    ____________________________
    Degree:
    Master of Arts in Nursing
    __
    PRC Lic. No. : 0158815
    __
    Valid Until:
    May 4, 2013__________________
    PNA No. :
    2011-041254_________________
    Valid Until:
    December 2012_______________

    ___________________________________________
    Signature over printed name of Chief Nurse
    Date signed: _______________________________
    Degree:
    _______________________________
    PRC Lic. No.: _______________________________
    Valid Until:
    _______________________________
    PNA No. :
    _______________________________
    Valid Until:
    _______________________________

    ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________


    Signature over printed name of Dean
    Date signed:
    ______________________________________
    Degree:
    Doctor of Philosophy Major in Educational Management
    PRC Lic. No. : 78564_________________________________
    Valid Until:
    September 24, 2014_____________________
    PNA No. :
    2159__________________________________
    Valid Until:
    Lifetime_______________________________
    ADPCN No. : 11-351________________________________
    Valid Until:
    May 31, 2012___________________________

    FAR EASTERN UNIVERSITY


    Nicanor Reyes Sr. Street Sampaloc Manila 1008
    Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
    PAASCU, Level II Re-Accredited, May 2011
    MINOR SURGICAL SCRUB in _________________________________________________________________
    Hospital, Municipality/City/Province
    Prepared by:
    Printed Name with Signature of Student _________________________________________
    Date Performed
    and
    Time Started

    Patients INITIALS (only)


    SURGICAL PROCEDURE
    PERFORMED

    Case Number

    O.R. Nurse on Duty


    (Name and Signature)

    SUPERVISED BY
    Clinical Instructor
    (Name and Signature)

    Noted by:

    Concurred by:

    Approved by:

    MONICA C. LAGONOY - AONUEVO, RN, MAN__


    Signature over printed name of Clinical Coordinator
    Date signed:
    ____________________________
    Degree:
    Master of Arts in Nursing
    __
    PRC Lic. No. : 0158815
    __
    Valid Until:
    May 4, 2013__________________
    PNA No. :
    2011-041254_________________
    Valid Until:
    December 2012_______________

    ___________________________________________
    Signature over printed name of Chief Nurse
    Date signed: _______________________________
    Degree:
    _______________________________
    PRC Lic. No.: _______________________________
    Valid Until:
    _______________________________
    PNA No. :
    _______________________________
    Valid Until:
    _______________________________

    ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________


    Signature over printed name of Dean
    Date signed:
    ______________________________________
    Degree:
    Doctor of Philosophy Major in Educational Management
    PRC Lic. No. : 78564_________________________________
    Valid Until:
    September 24, 2014_____________________
    PNA No. :
    2159__________________________________
    Valid Until:
    Lifetime_______________________________
    ADPCN No. : 11-351________________________________
    Valid Until:
    May 31, 2012___________________________

    FAR EASTERN UNIVERSITY


    Nicanor Reyes Sr. Street Sampaloc Manila 1008
    Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
    PAASCU, Level II Re-Accredited, May 2011
    ACTUAL DELIVERY in _______________________________________________________________________
    Hospital, Municipality/City/Province
    Prepared by:
    Printed Name with Signature of Student _________________________________________
    Date Performed
    and
    Time Started

    Patients INITIALS (only)


    PROCEDURE PERFORMED
    ASSISTED DELIVERY

    Case Number
    (Not applicable for Birthing/Lying-In Clinics/Homes)

    D.R. Nurse on Duty


    (Name and Signature)
    (If Midwife on Duty,
    Signature not Required)

    SUPERVISED BY
    Clinical Instructor
    (Name and Signature)

    Noted by:

    Concurred by:

    Approved by:

    MONICA C. LAGONOY - AONUEVO, RN, MAN__


    Signature over printed name of Clinical Coordinator
    Date signed:
    ____________________________
    Degree:
    Master of Arts in Nursing
    __
    PRC Lic. No. : 0158815
    __
    Valid Until:
    May 4, 2013__________________
    PNA No. :
    2011-041254_________________
    Valid Until:
    December 2012_______________

    ___________________________________________
    Signature over printed name of Chief Nurse
    Date signed: _______________________________
    Degree:
    _______________________________
    PRC Lic. No.: _______________________________
    Valid Until:
    _______________________________
    PNA No. :
    _______________________________
    Valid Until:
    _______________________________

    ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________


    Signature over printed name of Dean
    Date signed:
    ______________________________________
    Degree:
    Doctor of Philosophy Major in Educational Management
    PRC Lic. No. : 78564_________________________________
    Valid Until:
    September 24, 2014_____________________
    PNA No. :
    2159__________________________________
    Valid Until:
    Lifetime_______________________________
    ADPCN No. : 11-351________________________________
    Valid Until:
    May 31, 2012___________________________

    FAR EASTERN UNIVERSITY


    Nicanor Reyes Sr. Street Sampaloc Manila 1008
    Tel. No.: (632) 735-8713, Fax No.: (632) 736-0010, Email: IN@feu.edu.ph, Website: www.feu.edu.ph
    PAASCU, Level II Re-Accredited, May 2011
    IMMEDIATE NEWBORN CARE in ______________________________________________________________
    Hospital, Municipality/City/Province
    Prepared by:
    Printed Name with Signature of Student _________________________________________
    Date Performed
    and
    Time Started

    Patients INITIALS (only)


    Case Number

    Immediate Newborn Cord Care


    PERFORMED

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

    Indicate where performed e.g. D.R., Nursery, NICU, or Home

    D.R. Nurse on Duty


    (Name and Signature)
    (If Midwife on Duty,
    Signature not Required)

    SUPERVISED BY
    Clinical Instructor
    (Name and Signature)

    Noted by:

    Concurred by:

    Approved by:

    MONICA C. LAGONOY - AONUEVO, RN, MAN__


    Signature over printed name of Clinical Coordinator
    Date signed:
    ____________________________
    Degree:
    Master of Arts in Nursing
    __
    PRC Lic. No. : 0158815
    __
    Valid Until:
    May 4, 2013__________________
    PNA No. :
    2011-041254_________________
    Valid Until:
    December 2012_______________

    ___________________________________________
    Signature over printed name of Chief Nurse
    Date signed: _______________________________
    Degree:
    _______________________________
    PRC Lic. No.: _______________________________
    Valid Until:
    _______________________________
    PNA No. :
    _______________________________
    Valid Until:
    _______________________________

    ROSALINDA P. SALUSTIANO, RN, RM, MAN, PhD________


    Signature over printed name of Dean
    Date signed:
    ______________________________________
    Degree:
    Doctor of Philosophy Major in Educational Management
    PRC Lic. No. : 78564_________________________________
    Valid Until:
    September 24, 2014_____________________
    PNA No. :
    2159__________________________________
    Valid Until:
    Lifetime_______________________________
    ADPCN No. : 11-351________________________________
    Valid Until:
    May 31, 2012___________________________

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