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New Forms of Cases PRC 2

This document contains forms for medical students to log their surgical scrubs, actual deliveries, and assisted deliveries in various hospitals and clinics. The forms require the student's name and signature, dates and times of procedures, patient initials, case numbers if applicable, procedures performed, supervising nurses or midwives, and signatures from the clinical coordinator and dean to verify the records.

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Corenne Hope Obado
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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59 views6 pages

New Forms of Cases PRC 2

This document contains forms for medical students to log their surgical scrubs, actual deliveries, and assisted deliveries in various hospitals and clinics. The forms require the student's name and signature, dates and times of procedures, patient initials, case numbers if applicable, procedures performed, supervising nurses or midwives, and signatures from the clinical coordinator and dean to verify the records.

Uploaded by

Corenne Hope Obado
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SCHOOL OF MEDICAL SCIENCES

OR Circulating Form
Accredited Level II –ACSCU-AAI: May 2023 - May 2026

Surgical Scrub in ________________________________________________


Hospital, Municipality/City/Province

Prepared by:
Name of Student: __________________________________ Signature of Student: _________________________________________

Date Performed Patient’s Initial Only SUPERVISEDBY


And Procedure Performed OR Nurse on Duty (Name Only) Clinical Instructor
Time Started Case Number Name and Signature

Noted by: Concurred by:

LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: _________________ Date Signed: __________________
Time Signed:_________________ Time Signed: _________________
Degree: RN, MAN_______________ Degree: RN, MSN_______________
a. PRC No. 0279667____________ a. PRC No. 0270024____________
Valid until: October 12, 2023_ Valid until: November 17, 2025
b. PNA No. _____________ b. PNA No. _______________
Valid until: ____________ Valid until: _____________
c. ADPCN No. 11-304
Valid until: _________
SCHOOL OF MEDICAL SCIENCES
Actual Form
Accredited Level II –ACSCU-AAI: May 2023 - May 2026

Actual Deliveries in ________________________________________________


Hospital, Municipality/City/Province

Prepared by:
Name of Student: __________________________________ Signature of Student: ______________________________________ _________

Patient’s Initial Only


Date Performed D.R. Nurse/Midwife SUPERVISED BY
And Case Number Procedure Performed On Duty Clinical Instructor
Time Started (not applicable for Birthing/Lying- (Name only) Name and Signature
In Clinics/Homes)

Noted by: Concurred by:

LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: _________________ Date Signed: __________________
Time Signed:_________________ Time Signed: _________________
Degree: RN, MAN_______________ Degree: RN, MSN_______________
b. PRC No. 0279667____________ a. PRC No. 0270024____________
Valid until: October 12, 2023_ Valid until: November 17, 2025
c. PNA No. _____________ b. PNA No. _______________
Valid until: ____________ Valid until: _____________
c. ADPCN No. 11-304
Valid until: _________

SCHOOL OF MEDICAL SCIENCES Assist


Form
Accredited Level II –ACSCU-AAI: May 2023 - May 2026

ASSISTED DELIVERY in _________________________________________________


Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Student: __________________________________ Signature of Student: _________________________________________

Patient’s Initial Only


Date Performed D.R. Nurse/Midwife SUPERVISED BY
And Case Number Procedure Performed On Duty Clinical Instructor
Time Started (not applicable for Birthing/Lying- (Name only) Name and Signature
In Clinics/Homes)

Noted by: Concurred by:

LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: _________________ Date Signed: __________________
Time Signed:_________________ Time Signed: _________________
Degree: RN, MAN_______________ Degree: RN, MSN_______________
c. PRC No. 0279667____________ a. PRC No. 0270024____________
Valid until: October 12, 2023_ Valid until: November 17, 2025
d. PNA No. _____________ b. PNA No. _______________
Valid until: ____________ Valid until: _____________
c. ADPCN No. 11-304
Valid until: _________
SCHOOL OF MEDICAL SCIENCES
Cord Care Form
Accredited Level II –ACSCU-AAI: May 2023 - MAy 2026

IMMEDIATE NEWBORN CORD CARE in ___________________________________________________


Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Name of Student: __________________________________ Signature of Student: _________________________________________

Patient’s Initial Only Immediate Newborn Cord Care


Date Performed PERFORMED D.R. Nurse/Midwife SUPERVISED BY
And Case Number Indicate where performed e.g. D.R., On Duty Clinical Instructor
Time Started (not applicable for Birthing/Lying- Nursery, (Name only) Name and Signature
In Clinics/Homes) NICU, or Home

Noted by: Concurred by:

LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: _________________ Date Signed: __________________
Time Signed:_________________ Time Signed: _________________
Degree: RN, MAN_______________ Degree: RN, MSN_______________
d. PRC No. 0279667____________ a. PRC No. 0270024____________
Valid until: October 12, 2023_ Valid until: November 17, 2025
e. PNA No. _____________ b. PNA No. _______________
Valid until: ____________ Valid until: _____________
c. ADPCN No. 11-304
Valid until: _________

SCHOOL OF MEDICAL SCIENCES


OR Scrub Form
Accredited Level II –ACSCU-AAI: May 2023 - May 2026

Surgical Scrub in ________________________________________________


Hospital, Municipality/City/Province

Prepared by:
Name of Student: __________________________________ Signature of Student: _________________________________________

Date Performed Patient’s Initial Only SUPERVISEDBY


And Procedure Performed OR Nurse on Duty (Name Only) Clinical Instructor
Time Started Case Number Name and Signature

Noted by: Concurred by:

LETICIA D. SERRANO_____________________ MARIVIC D. DELA TORRE_________


Signature over printed name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed: _________________ Date Signed: __________________
Time Signed:_________________ Time Signed: _________________
Degree: RN, MAN_______________ Degree: RN, MSN_______________
e. PRC No. 0279667____________ a. PRC No. 0270024____________
Valid until: October 12, 2023_ Valid until: November 17, 2025
f. PNA No. _____________ b. PNA No. _______________
Valid until: ____________ Valid until: _____________
c. ADPCN No. 11-304
Valid until: _________

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