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Surgical Procedure Performed

This document contains forms for students to document their surgical scrub and circulating experiences at De La Salle University Medical Center. The forms require the student's name, date and time of the procedure, patient initials, case number, surgical procedure performed, supervising nurse and instructor. The forms must be signed by the student, approved by the level 3 coordinator and dean with their nursing credentials.

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Dominic Bristol
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77 views2 pages

Surgical Procedure Performed

This document contains forms for students to document their surgical scrub and circulating experiences at De La Salle University Medical Center. The forms require the student's name, date and time of the procedure, patient initials, case number, surgical procedure performed, supervising nurse and instructor. The forms must be signed by the student, approved by the level 3 coordinator and dean with their nursing credentials.

Uploaded by

Dominic Bristol
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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DE LA SALLE HEALTH SCIENCES INSTITUTE ODC Form 2A

City of Dasmariñas, Cavite 4114, Philippines O.R. SCRUB FORM


(Cavite Line) 481-8000 (Manila Line) 988-3100, Fax (046) 481-8011 Major
www.dlshsi.edu.ph
PAASCU Accredited – Level 3 November 2014 – November 2019

SURGICAL SCRUB IN DE LA SALLE UNIVERSITY MEDICAL CENTER, CITY of DASMARIÑAS, CAVITE


Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY


and (Name AND Signature) Clinical Instructor
Time Started
Case Number SURGICAL PROCEDURE Name and Signature

PERFORMED

Noted by: LEON L. FOJAS, RN, MAN Approved by: _________________________________________


(Printed Name and Signature) (Printed Name and Signature)
Level 3 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: ____
DE LA SALLE HEALTH SCIENCES INSTITUTE ODC Form 2B
City of Dasmariñas, Cavite 4114, Philippines O.R. CIRCULATING
(Cavite Line) 481-8000 (Manila Line) 988-3100, Fax (046) 481-8011 FORM
www.dlshsi.edu.ph
Major
PAASCU Accredited – Level 3 November 2014 – November 2019

CIRCULATING IN DE LA SALLE UNIVERSITY MEDICAL CENTER, CITY of DASMARIÑAS, CAVITE


Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student

Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY


and (Name AND Signature) Clinical Instructor
Time Started
Case Number SURGICAL PROCEDURE Name and Signature

PERFORMED

Noted by: __________________________________ Approved by: ______________________________


(Printed Name and Signature) (Printed Name and Signature)
Level 3 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: _______________

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