REPUBLIC OF THE PHILIPPINES
VISAYAS STATE UNIVERSITY
College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226
ACTUAL DELIVERY in __________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
D.R. FORM
ACTUAL DELIVERY
FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________
Date Performed
and
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
Endorsed by: ___________________________________________________
_____________________________________________________
(Print Name and Signature)
Name and Signature)
Delivery Room Coordinator, PRC ID No. ____________ Valid Until _______
Valid Until _______
Noted by:
Date Document is signed: ____________________________
Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________
Date Document is signed: ____________________________
(Print
Clinical Coordinator, PRC ID No. __________________
Please specify Highest Nursing Degree Earned:
Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: ______________________________
REPUBLIC OF THE PHILIPPINES
VISAYAS STATE UNIVERSITY
College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226
ACTUAL ASSIST in __________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
D.R. FORM
ACTUAL ASSIST
FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________
Date Performed
and
Started
Patients INITIAL Only
Case Number
PROCEDURE
PERFORMED
D.R. Nurse on Duty
(Name and Signature)
(If Midwife on Duty,
SUPERVISED BY
Clinical Instructor
Time:
(not applicable for Birthing/
Lying-in Clinics/Homes)
Signature not Required)
Name and
Signature
Endorsed by: ___________________________________________________
_____________________________________________________
(Print Name and Signature)
Name and Signature)
Delivery Room Coordinator, PRC ID No.____________ Valid Until _______
Valid Until _______
Noted by:
Date Document is signed: ____________________________
Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________
Date Document is signed: ____________________________
(Print
Clinical Coordinator, PRC ID No. __________________
Please specify Highest Nursing Degree Earned:
Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: ______________________________
Time:
REPUBLIC OF THE PHILIPPINES
VISAYAS STATE UNIVERSITY
College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226
IMMEDIATE NEWBORN CORD CARE in __________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
ICNB FORM
IMMEDIATE CARE OF THE
NEWBORN FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________
Date Performed
and
Started
Patients INITIAL Only
Case Number
(not applicable for Birthing/
Lying-in Clinics/Homes)
Immediate Newborn Cord
Care PERFORMED
(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
Endorsed by: ___________________________________________________
_____________________________________________________
(Print Name and Signature)
Name and Signature)
Delivery Room Coordinator, PRC ID No.____________ Valid Until _______
Valid Until _______
Noted by:
Date Document is signed: ____________________________
Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________
Date Document is signed: ____________________________
(Print
Clinical Coordinator, PRC ID No. __________________
Please specify Highest Nursing Degree Earned:
Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: ______________________________
REPUBLIC OF THE PHILIPPINES
VISAYAS STATE UNIVERSITY
College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226
SURGICAL SCRUB in __________________________________________________________________
Hospital, Municipality/City/Province
O.R. FORM 1 A
O.R. SCRUB FORM
Major
Prepared by:
Printed Name and Signature of Student___________________________________________________
Date Performed
and
Started
Patients INITIAL Only
Case Number
PROCEDURE
PERFORMED
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Time:
Name and
Signature
Endorsed by: ___________________________________________________
_____________________________________________________
(Print Name and Signature)
Name and Signature)
Operating Room Coordinator, PRC ID No. ____________ Valid Until _______
Valid Until _______
Noted by:
Date Document is signed: ____________________________
Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________
Date Document is signed: ____________________________
(Print
Clinical Coordinator, PRC ID No. __________________
Please specify Highest Nursing Degree Earned:
Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: __________________________
Time:
REPUBLIC OF THE PHILIPPINES
VISAYAS STATE UNIVERSITY
College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226
SURGICAL SCRUB in __________________________________________________________________
Hospital, Municipality/City/Province
O.R. FORM 1B
O.R. CIRCULATING
FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________
Date Performed
and
Started
Patients INITIAL Only
Case Number
PROCEDURE
PERFORMED
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY
Clinical Instructor
Name and
Signature
Endorsed by: ___________________________________________________
_____________________________________________________
(Print Name and Signature)
Name and Signature)
Operating Room Coordinator, PRC ID No. ____________ Valid Until _______
Valid Until _______
Noted by:
Date Document is signed: ____________________________
Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________
Date Document is signed: ____________________________
(Print
Clinical Coordinator, PRC ID No. __________________
Please specify Highest Nursing Degree Earned:
Approved by: ___________________________________________________
(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: __________________________
Time:
