UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
SURGICAL SCRUB in CEBU CITY MEDICAL CENTER
Prepared by:
O.R. FORM 1A
O.R. SCRUB
FORM
______________________________
LEONIDA N. MUEZ
Date
Performed and
Time Started
PATIENTS
Initials Only
Case Number
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse on Duty
(Complete Name and
Signature)
May 20, 2011
8:27 AM
F.B.G.
432044
Exploratory, Laparotomy Right
Hemicolectomy (Gastro-intestinal
Anastomosis) with Side to Side
Anastomosis Application of Internal
Retraction Suture (Tumor4 Node1
Metastasis0)
Ms. Ofelia B. Songahid
R.N.
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Ms. Maria Flordeliz G.
Padayao, R.N., M.A.N.
Approved by: _______________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:___________________
UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
SURGICAL CIRCULATING in __________________________________________________
Prepared by:
O.R. FORM 1B
O.R. CIRCULATING
FORM
_________________________________
Date Performed
and Time
Started
PATIENTS
Initials Only
Case Number
SURGICAL PROCEDURE
PERFORMED
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS, R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
O.R. Nurse on Duty
(Complete Name and
Signature)
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Approved by: ____________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:___________________
UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
ACTUAL DELIVERY in _______________________________________________________
Prepared by:
_________________________________
Date
Performed and
Time Started
PATIENTS
Initials Only
Case Number
PROCEDURE
PERFORMED
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS, R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
D.R. FORM
ACTUAL DELIVERY
FORM
D.R. Nurse on Duty
(Complete Name and
Signature)
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Approved by: _______________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:___________________
UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
IMMEDIATE NEWBORN CORD CARE in ____________________________________________________
Prepared by:
__________________________________
Date
Performed and
Time Started
PATIENTS
Initials Only
Case Number
IMMEDIATE NEWBORN
CORD CARE
PERFORMED
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS, R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
ICNB FORM
IMMEDIATE CARE OF
THE NEWBORN FORM
D.R. Nurse on Duty
(Complete Name and
Signature)
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Approved by: _______________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:___________________
UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
SURGICAL SCRUB in CEBU CITY MEDICAL CENTER
Prepared by:
O.R. FORM 1A
O.R. SCRUB
FORM
______________________________
RANI MAE P. VALENZONA
Date
Performed and
Time Started
PATIENTS
Initials Only
Case Number
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse on Duty
(Complete Name and
Signature)
March 13, 2012
10:00 AM
E.S.S
506020
Open Reduction Internal Fixation
(Log Screw Fixation) Medial
Malleolus Left; Open Reduction
Internal Fixation Plate and Screw
Fibula Left
Mr. Romil Galahad M.
Blancas, R.N
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Ms. Maria Flordeliz G.
Padayao, R.N., M.A.N
Approved by: _______________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:___________________
UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
SURGICAL SCRUB in CEBU CITY MEDICAL CENTER
Prepared by:
O.R. FORM 1A
O.R. SCRUB
FORM
______________________________
RANI MAE P. VALENZONA
Date
Performed and
Time Started
PATIENTS
Initials Only
Case Number
SURGICAL PROCEDURE
PERFORMED
O.R. Nurse on Duty
(Complete Name and
Signature)
March 12, 2012
10:07 AM
J.L.P.E
507081
Abdomino-Endo Rectal Pull
Through Take Down of Colostomy
Mr. Jason Noel A.
Manigos, R.N
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Ms. Maria Flordeliz G.
Padayao, R.N., M.A.N
Approved by: _______________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:___________________
UNIVERSITY OF CEBU BANILAD CAMPUS
College of Nursing
Governor Cuenco Avenue, Banilad, Cebu City 6000
(032) 233-8888; (032) 231-8613; www.uc.edu.ph
PACUCOA Level II 3rd Reaccredited Status, June 2007
SURGICAL SCRUB in ____________________________________________________________
Prepared by:
O.R. FORM 1A
O.R. SCRUB
FORM
______________________________
Date
Performed and
Time Started
PATIENTS
Initials Only
Case Number
SURGICAL PROCEDURE
PERFORMED
Noted by: ____________________________________________
PILUCHI VICTORINA M. VILLEGAS R.N., M.N
Clinical Coordinator
PRC I.D No. ___________ Valid Until ____________
Date document is signed: _______________________
Time: _______________________
Highest Nursing Degree Earned:_________________
O.R. Nurse on Duty
(Complete Name and
Signature)
Supervised by Clinical
Instructor
(Complete Name and
Signature)
Approved by: _______________________________________
DR. HELEN C. ESTRELLA
Dean
PRC I.D. No. ____________ Valid Until _____________
Date document is signed: _________________________
Time: _______________________
Highest Nursing Degree Earned:__________________
