O.R.
Form 1A
Misamis University O.R. SCRUB FORM
Ozamiz City Major
College of Nursing and School of Midwifery
Tel Nos. (088) 521-0367, 521-0431/ Telefax No.: (088) 521-2917
Email Address: mu@mu.edu.ph
Accreditation: PACUCOA Level II Second Reaccredited Status Inclusive Date of Accreditation: December 2014- December 2019
Certification: ISO 9001: 2015 Risk Management System – Det Norske Veritas, The Netherlands
SURGICAL SCRUB in ______________________________________________________________________________
(Hospital, Municipality/City/Province)
Prepared by:
Date Performed Patient’s INITIALS only O.R. Nurse on Duty SUPERVISED BY Clinical Instructor
SURGICAL PROCEDURE PERFORMED
and Time Started Case Number (Name and Signature) (Name and Signature)
Noted by: Approved by:
_________________
Clinical Coordinator _______________
PRC ID No. _______ Valid Until: __________ Dean
Date document is signed: Time: PRC ID No. ___________ Valid Until: ___________
Highest Nursing Degree Earned: Date document is signed: Time:
Highest Nursing Degree Earned:
O.R. Form 1B
O.R. CIRCULATING
Misamis University FORM
Ozamiz City
College of Nursing and School of Midwifery
Tel Nos. (088) 521-0367, 521-0431/ Telefax No.: (088) 521-2917
Email Address: mu@mu.edu.ph
Accreditation: PACUCOA Level II Second Reaccredited Status Inclusive Date of Accreditation: December 2014- December 2019
Certification: ISO 9001: 2015 Risk Management System – Det Norske Veritas, The Netherlands
SURGICAL SCRUB in ______________________________________________________________________________
(Hospital, Municipality/City/Province)
Prepared by:
Date Performed Patient’s INITIALS only O.R. Nurse on Duty SUPERVISED BY Clinical Instructor
SURGICAL PROCEDURE PERFORMED
and Time Started Case Number (Name and Signature) (Name and Signature)
Noted by: Approved by:
_________________
Clinical Coordinator _______________
PRC ID No. _______ Valid Until: __________ Dean
Date document is signed: Time: PRC ID No. ___________ Valid Until: ___________
Highest Nursing Degree Earned: Date document is signed: Time:
Highest Nursing Degree Earned:
D.R. Form
ASSISTED DELIVERY
Misamis University Form
Ozamiz City
College of Nursing and School of Midwifery
Tel Nos. (088) 521-0367, 521-0431/ Telefax No.: (088) 521-2917
Email Address: mu@mu.edu.ph
Accreditation: PACUCOA Level II Second Reaccredited Status Inclusive Date of Accreditation: December 2014- December 2019
Certification: ISO 9001: 2015 Risk Management System – Det Norske Veritas, The Netherlands
ACTUAL DELIVERY in MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER, MANINGCOL, OZAMIZ CITY
(Hospital, Municipality/City/Province)
Prepared by:
Date Performed Patient’s INITIALS only D.R. Nurse on Duty SUPERVISED BY Clinical Instructor
PROCEDURE PERFORMED
and Time Started Case Number (Name and Signature) (Name and Signature)
Noted by: Approved by:
_________________
Clinical Coordinator _______________
PRC ID No. _______ Valid Until: __________ Dean
Date document is signed: Time: PRC ID No. ___________ Valid Until: ___________
Highest Nursing Degree Earned: Date document is signed: Time:
Highest Nursing Degree Earned:
D.R. Form
ACTUAL DELIVERY
Misamis University Form
Ozamiz City
College of Nursing and School of Midwifery
Tel Nos. (088) 521-0367, 521-0431/ Telefax No.: (088) 521-2917
Email Address: mu@mu.edu.ph
Accreditation: PACUCOA Level II Second Reaccredited Status Inclusive Date of Accreditation: December 2014- December 2019
Certification: ISO 9001: 2015 Risk Management System – Det Norske Veritas, The Netherlands
ACTUAL DELIVERY in MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER, MANINGCOL, OZAMIZ CITY
(Hospital, Municipality/City/Province)
Prepared by:
Date Performed Patient’s INITIALS only D.R. Nurse on Duty SUPERVISED BY Clinical Instructor
PROCEDURE PERFORMED
and Time Started Case Number (Name and Signature) (Name and Signature)
Noted by: Approved by:
_________________
Clinical Coordinator _______________
PRC ID No. _______ Valid Until: __________ Dean
Date document is signed: Time: PRC ID No. ___________ Valid Until: ___________
Highest Nursing Degree Earned: Date document is signed: Time:
Highest Nursing Degree Earned:
ICNB Form
IMMEDIATE CARE OF
Misamis University THE NEWBORN FORM
Ozamiz City
College of Nursing and School of Midwifery
Tel Nos. (088) 521-0367, 521-0431/ Telefax No.: (088) 521-2917
Email Address: mu@mu.edu.ph
Accreditation: PACUCOA Level II Second Reaccredited Status Inclusive Date of Accreditation: December 2014- December 2019
Certification: ISO 9001: 2015 Risk Management System – Det Norske Veritas, The Netherlands
IMMEDIATE NEWBORN CORD CARE in MAYOR HILARION A. RAMIRO SR. MEDICAL CENTER, MANINGCOL, OZAMIZ CITY __
(Hospital, Municipality/City/Province)
Prepared by:
Date Performed Patient’s INITIALS only D.R. Nurse on Duty SUPERVISED BY Clinical Instructor
PROCEDURE PERFORMED
and Time Started Case Number (Name and Signature) (Name and Signature)
Noted by: Approved by:
_________________
Clinical Coordinator _______________
PRC ID No. _______ Valid Until: __________ Dean
Date document is signed: Time: PRC ID No. ___________ Valid Until: ___________
Highest Nursing Degree Earned: Date document is signed: Time:
Highest Nursing Degree Earned:
