UNIVERSIDAD DE MANILA

A.J. Villegas St. Mehan Garden, Ermita, Manila

College of Health Sciences
Department of Nursing

Name of Student:______________________ First Course (If any): N/A School Graduated From: N/A Year: N/A
Name of School: Universidad De Manila (formerly City College of Manila) Year of Admission in the Bachelor of Science in Nursing Program: ______
Address of School: A.J Villegas St. Mehan Garden, Ermita, Manila Year Graduated (BSN Program): ______
Accreditation Level (If any):_N/A_Year Granted: N/A
Date School/ Program was recognized: Number: _N/A_Year: N/A
Name of Hospital: __________________________

V. CORD CARE

N C a s e Date Name of Gender of N a m e o f A g Name and Signature of Clinical Name and Signature of Qualified
o N o . Performed Baby Baby M o t h e r e Instructor Clinical Instructor
1
.
2
.
3
.

4
.

5
.

Noted By: Concurred By:

ASUNCION C. BALISADO, RN, MAN _________________________, RN, MAN

Chief Nurse, Ospital ng Maynila Medical Center Dean, College of Health Sciences
Date signed:__________ Date signed: ______________
PRC Lic. No.: _________ PRC Lick. No.: _____________
Valid Until: __________ Valid Until: _______________
PNA No.: ____________ PNA No.: ________________
Valid Until: __________ Valid Until: _______________
ANSAP No.: _________
Valid Until: ____________
 UNIVERSIDAD DE MANILA
A.J. Villegas St. Mehan Garden, Ermita, Manila
College of Health Sciences
Department of Nursing

Name of Student: ______________________ First Course (If any): N/A School Graduated from: N/A Year: N/A
Name of School: Universidad De Manila (formerly City College of Manila) Year of Admission in the Bachelor of Science in Nursing Program: ______
Address of School: A.J Villegas St. Mehan Garden, Ermita, Manila Year Graduated (BSN Program): _____
Accreditation Level (If any):_N/A_Year Granted: N/A
Date School/ Program was recognized: Number: _N/A_Year: N/A
Name of Hospital: __________________________

III. DELIVERIES HANDLED

No Case D i a g n o s i Name of Ag Date of Time of Gender of Ty p e o f Name and Signature of Clinical Name and Signature of Qualified
. No. s Mother e Delivery Delivery Baby Delivery Instructor Clinical Instructor
Gravidity 1 Lelis, Ma. 2 February 15, 9 : 1 7 a Fe m a l e Normal Elizabeth D. Cruz RN,
2777103 Pa rity 0 Claudi a 3 2015 m Spontaneous MAN
1. Pregnancy Uterine 36 Delivery
weeks
and 6 days AOG
277929 Gravidity 1 Delos 1 February 4, 10:50a M a l e Normal Elizabeth D. Cruz RN,
6 Pa rity 0 Reyes , 6 2015 m Spontaneous MAN
2.
Pregnancy Uterine 39 Manenele Delivery
weeks AOG
277727 Gr avidity 3 Pari ty Zamora, 2 January 28, 6 : 1 4 a M a l e Normal Elizabeth D. Cruz RN,
6 2 Rusalla 9 2015 m Spontaneous MAN
3.
Pregnancy Uterine 37 Delivery
weeks AOG
Gravidity 2 Santos, 1 January 28, 12:05n Fe m a l e Normal Elizabeth D. Cruz RN,
2777375 Pa rity 1 Micah 8 2015 n Spontaneous MAN
4.
Pregnancy Uterine 37 Delivery
weeks AOG
277720 Gr avidity 8 Pari ty Bachon, 3 January 27, 12:49n Fe m a l e Normal Elizabeth D. Cruz RN,
9 7 Bernadette 5 2015 n Spontaneous MAN
5. Pregnancy Uterine 39 Delivery
weeks and
4 days AOG

Noted By: Concurred By:

 ASUNCION C. BALISADO, RN, MAN __________________________, RN, MAN
Chief Nurse, Hospital ng Maynila Medical Center Dean, College of Health Sciences
Date signed: ____________ Date signed: ______________
PRC Lick. No.: ___________ PRC Lic. No.: _____________
Valid Until: ____________ Valid Until: _______________
PNA No.: ______________ PNA No.: ________________
Valid Until: ____________ Valid Until: _______________
ANSAP No.: ____________
Valid Until: _______________

UNIVERSIDAD DE MANILA
A.J. Villegas St. Mehan Garden, Ermita, Manila
College of Health Sciences
Department of Nursing

Name of Student: _________________________ First Course (If any): N/A School Graduated from: N/A Year: N/A
Name of School: Universidad De Manila (formerly City College of Manila) Year of Admission in the Bachelor of Science in Nursing Program: ______
Address of School: A.J Villegas St. Mehan Garden, Ermita, Manila Year Graduated (BSN Program): ______
Accreditation Level (If any):_N/A_Year Granted: N/A
Date School/ Program was recognized: Number: _N/A_Year: N/A
Name of Hospital :___________________________

IV. DELIVERIES ASSISTED

N o Case D i a g
n o s i Name of Ag Date of Time of Gender of Ty p e o f Name and Signature of Clinical Name and Signature of Qualified
. No. s Mother e Delivery Delivery Baby Delivery Instructor Clinical Instructor
277903 Gravidity 3 Candelari 3 February 2, 9 : 3 3 a Fe m a l e Normal Elizabeth D. Cruz RN,
1 0 Parity 2 a, 9 2015 m Spontaneous MAN
. Pregnancy Uterine 40 Eliza Delivery
weeks and Moseguera
4 days AOG
277932 Gravidity 6 Mendoza, 3 February 4, 9 : 1 5 a Fe m a l e Normal Elizabeth D. Cruz RN,
2 6 Parity 5 Re a h 3 2015 m Spontaneous MAN
. Pregnancy Uterine 40 Delivery
weeks AOG
278120 Gravidity 2 Malate, 2 February 10, 6 : 5 8 a Fe m a l e Normal Elizabeth D. Cruz RN,
3 0 Parity 1 Jonalyn 0 2015 m Spontaneous MAN
. Pregnancy Uterine 40 Delivery
weeks
and 2 days AOG
175869 Gravidity 1 Umadhoy, Ma. 2 January 28, 6 : 5 8 a M a l e Normal Elizabeth D. Cruz RN,
4 2 Parity 0 Shalee 6 2015 m Spontaneous MAN
. Pregnancy Uterine 39 Delivery
weeks and
 3 days AOG

277721 Gravidity 1 Ramos, 2 January 27, 12:2 9n M a l e Normal Elizabeth D. Cruz RN,
5 0 Parity 0 Milagrose 2 2015 n Spontaneous MAN
. Pregnancy Uterine 38 Delivery
weeks and
6 days AOG

Noted by: Concurred by:

ASUNCION C. BALISADO, RN, MAN __________________________, RN, MAN

Chief Nurse, Ospital ng Maynila Medical Center Dean, College of Health Sciences
Date signed_______________ Date signed: ______________
PRC Lick. No.:_____________ PRC Lic. No.: _____________
Valid Until: ______________ Valid Until: _______________
PNA No.: ________________ PNA No.: ________________
Valid Until: ______________ Valid Until: ______________
ANSAP No_______________
Valid Until: _________________

UNIVERSIDAD DE MANILA
A.J. Villegas St. Mehan Garden, Ermita, Manila
College of Health Sciences
Department of Nursing

Name of Student: __________________________ First Course (If any): N/A School Graduated from: N/A Year: N/A
Name of School: Universidad De Manila (formerly City College of Manila) Year of Admission in the Bachelor of Science in Nursing Program: ______
Address of School: A.J Villegas St. Mehan Garden, Ermita, Manila Year Graduated (BSN Program): ______
Accreditation Level (If any):_N/A_Year Granted: N/A
Date School/ Program was recognized: Number: _N/A_Year: N/A
Name of Hospital :___________________

II. MINOR OPERATIONS

N o . Date of Operation Case No. Name of Patient D i a g n o s i s Operation Performed Type of Anesthesia Name of Surgeon Name and Signature of Clinical Instructor Name and Signature of Qualified Clinical Instructor
Name of O.R. Scrub Nurse
1 June 27, 2015 153728 Adel, Paula Gravidit y 1 Parity 0 Curettage, Complete IV Sedation Revy Calling MD Celia R. Recel RN, MAN G A T
Incomplete Abortion

2 July 14, 2016 1809280 Prado, Amormio Infected sebaceous cyst Excision of L o c a l Benjamin Lucas MD Ma. Gracia M. Aliza RN Elizabeth D. Cruz RN, MAN O M
Paravertebral Area Sebaceous Cyst
Right
 September 8, 2016 16-38435 Reyes, Joseph Papilloma Left Buttock s Excision of Papilloma L o c a l Rhoda San Diego MD Virginia Isidro R N Kathleen D. Acunin RN, MA N G A T
3 Gluteal Area Left Buttocks
Gluteal Area
September 9, 2016 156202 Obregoso, Samuel Chronic Kidney Disease R i g h t F e m o r a l Ve i n L o c a l Naranjilla MD Kevin Miguel C. Rivera RN Kathleen D. Acunin RN, MA N G A T
4 Secondary to DM Ca t he t e r In s e r t ion
Nephropathy

Noted By: Concurred By:

ASUNCION C. BALISADO, RN, MAN __________________________, RN, MAN

Chief Nurse, Hospital ng Maynila Medical Center Dean, College of Health Sciences
Date signed: ______________ Date signed: ______________
PRC Lic. No.:_____________ PRC Lic. No.: _____________
Valid Until: ______________ Valid Until: _______________
PNA No.: ________________ PNA No.: ________________
Valid Until: ______________ Valid Until: _______________
ANSAP No.: ______________
Valid Until: ______________

UNIVERSIDAD DE MANILA
A.J. Villegas St. Mehan Garden, Ermita, Manila
College of Health Sciences
Department of Nursing

Name of Student: _______________________ First Course (If any): N/A School Graduated from: N/A Year: N/A
Name of School: Universidad De Manila (formerly City College of Manila) Year of Admission in the Bachelor of Science in Nursing Program: ______
Address of School: A.J Villegas St. Mehan Garden, Ermita, Manila Year Graduated (BSN Program): _______
Accreditation Level (If any):_N/A_Year Granted: N/A
Date School/ Program was recognized: Number: _N/A_Year: N/A
Name of Hospital : _________________________________

II. MAJOR OPERATIONS

N o . Date of Operation Case No. Name of Patient D i a g n o s i s Operation Performed Type of Anesthesia Name of Surgeon Name and Signature of Clinical Instructor Name and Signature of Qualified Clinical Instructor
Name of O.R. Scrub Nurse
1 February 4, 2016 2879155 Demetrio, Gravidity 6 Parity 4 L o w T r a n s v e r s e S A B Joyce Mae O. Peralta MD Martinez RN Myrna O. Iglesias RN, MAN O M
Elizabeth Pregnancy Uterine Cesarian Section
With BTL
2 September 9, 2016 100119 Lopez, Esperanza Gravidity 5 Parity 4 Low Transverse S A B Vill an ue va M D Amiel Bacudio RN Kathleen D. Acunin RN, MAN G A T
Pregnancy Uterine 37 Cesarian
 weeks
and 3 days AOG
September 9, 2016 160603 Munillo, Miriam Gravidity 4 Parity 4 Total Ab dominal Hysterectom y SAB/GA-LMA Maria Angela Sarmiento MD Abigail Cojeda RN Kathleen D. Acunin RN, MAN G A T
3 Abnormal Uterine With bilateral salphingo-
Bleeding Oophorectomy with
Secondary in Myoma adhesulysis
September 9, 2016 163726 Mariquit, Louie Gravidity 1 Parity 0 Emergency exploratory Laparotomy, S A B Maria Angela Sarmiento MD Kevin Miguel C Rivera RN Kathleen D. Acunin RN, MAN G A T
4 Jane 6-7 weeks AOG to Right Salphingectomy
consider
Ectopic Pregnancy
December 9, 2016 2923349 C o m p l e t e g u t E x p l o r a t o r y G E T A C a n l a s M D Lorraine Munsayac RN Rosalinda I. Morales RN, MAN
5 Teno, Anna Marie O b s t r u c t i o n l a p a r o t o m y O M
Marga

Noted By: Concurred By:

ASUNCION C. BALISADO, RN, MAN __________________________, RN, MAN

Chief Nurse, Ospital ng Maynila Medical Center Dean, College of Health Sciences
Date signed: _____________ Date signed: ______________
PRC Lic. No.: ____________ PRC Lic. No.: _____________
Valid Until: _____________ Valid Until: _______________
PNA No.: _______________ PNA No.: ________________
Valid Until: _____________ Valid Until: ______________
ANSAP No.: ____________
Valid Until: _______________

UNIVERSIDAD DE MANILA
A.J. Villegas St. Mehan Garden, Ermita, Manila
College of Health Sciences
Department of Nursing

Name of Student: _____________________________ First Course (If any): N/A School Graduated from: N/A Year: N/A
Name of School: Universidad De Manila (formerly City College of Manila) Year of Admission in the Bachelor of Science in Nursing Program: ___________
Address of School: A.J. Villegas St. Mehan Garden, Ermita, Manila Year Graduated (BSN Program):_____________
Accreditation Level (If any): N/A Year Granted: N/A
Date School/ Program was recognized: Number: N/A Year: N/A
Name of Hospital: _______________________

V. CORD CARE

No C a s e N o . Date Performed Name of Baby Gender of Baby N a m e o f M o t h e r Age Name of Clinical Instructor Name and Signature of Qualified Clinical Instructor

1 . 2 5 2 9 5 January 20, 2015 Baby girl Mucas F e m a l e M u c a s , G e n w i n 2 0 Rowena R. Hernandez RN, MA N J A S G E N

 2 4 8 1 5
2 . December 2, 2014 Baby girl Del Rosario F e m a l e Del Rosario, Ednalyn Rowena R. Hernandez RN, MA N J A S G E N

1 6 6 6 8 1
3 . January 5, 2017 Baby girl Anda M a l e A n d a , J u d y A n n 1 9 Clarisse Agno RN, MAN G A T
4 .
1 6 6 6 8 3 January 6, 2017 Baby boyRosadino M a l e Rosadino, Annabelle 3 1 Clarisse Agno RN, MAN G A T
5 .
1 5 2 4 4 6 January 5, 2017 B ab y gi r l P e r am a n F e m a l e Peraman, Roschell e 1 7 Clarisse Agno RN, MAN G A T

Noted by: Concurred By:

LUDIVINA V. LINEZO, RN, Ph.D. ___________________________, RN, MAN

Chief Nurse, Gat Andres Bonifacio Memorial Medical Center Dean, College of Health Sciences
Date signed: ________________ Date signed: ___________
PRC Lic. No.: _______________ PRC Lick. No.: __________
Valid Until: _________________ Valid Until: ____________
PNA No.: __________________ PNA No.: ______________
Valid Until: _________________ Valid Until: ____________
ANSAP No.: ________________
Valid Until: _________________