BUTUAN DOCTORS COLLEGE

J.C. AQUINO AVENUE, BUTUAN CITY Tel. No.(085)342-85-72; Fax No. (085)225-42-93 E-mail: registrar@butuandoctors.com.ph

SURGICAL SCRUB in ___________________________________________________________________

Hospital, Municipality/City/Province O.R. Form 1A

Prepared by: Printed Name and Signature of Student _________________________________________

Date Performed and Time Started Patients INITIALS (only) Case Number

O.R. SCRUB FORM Major

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RIZZA E. BESA, RN,MN Clinical Coordinator Butuan Doctors College a. PRC no.:__ 0246613________ Valid until: _January 22, 2015 b. PNA no. ___16734______ Valid Until: ___Lifetime__ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Noted by: JENNIFER H. ARANA, RN,MN Chair, Nursing Department Butuan Doctors College a. PRC no.:_0254651______ Valid until: March 28, 2013 b. PNA no.:____2012 - 058427____ Valid Until:__December 31, 2012_ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Approved by: PURITA R. ESCOBAR, RN,MAN,DM Dean, Butuan Doctors College a. PRC no.: 22566 Valid until: June 15, 2013 b. PNA no.: 26981 Valid Until: Lifetime c. ADPCN no.: ___11- 008____ Valid until: December 2012 Date Signed: Time: __________ Degree: BSN, MA in Nursing, Doctor of Management

BUTUAN DOCTORS COLLEGE

J.C. AQUINO AVENUE, BUTUAN CITY Tel. No.(085)342-85-72; Fax No. (085)225-42-93 E-mail: registrar@butuandoctors.com.ph

CIRCULATING in ___________________________________________________________________
Hospital, Municipality/City/Province

Prepared by: Printed Name and Signature of Student _________________________________________

Date Performed and Time Started Patients INITIALS (only) Case Number

O.R. Form 1B
O.R. CIRCULATING FORM

SURGICAL PROCEDURE PERFORMED

O.R. Nurse On Duty (Name and Signature)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RIZZA E. BESA, RN,MN Clinical Coordinator Butuan Doctors College a. PRC no.:__ 0246613________ Valid until: _January 22, 2015 b. PNA no. ___16734_____ Valid Until: ___Lifetime__ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Noted by: JENNIFER H. ARANA, RN,MN Chair, Nursing Department Butuan Doctors College a. PRC no.:_0254651______ Valid until: March 28, 2013 b. PNA no.:___ 2012 - 058427____ Valid Until:__December 31, 2012_ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Approved by:
PURITA R. ESCOBAR, RN,MAN,DM Dean, Butuan Doctors College a. PRC no.: 22566 Valid until: June 15, 2013 b. PNA no.: 26981 Valid Until: Lifetime c. ADPCN no.: ___11 - 008___ Valid until: December 2012 Date Signed: Time: __________ Degree: BSN, MA in Nursing, Doctor of Management

BUTUAN DOCTORS COLLEGE

J.C. AQUINO AVENUE, BUTUAN CITY Tel. No.(085)342-85-72; Fax No. (085)225-42-93 E-mail: registrar@butuandoctors.com.ph

ACTUAL DELIVERY in ___________________________________________________________________

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

Prepared by: Printed Name and Signature of Student _________________________________________

Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)

D. R. Form
ACTUAL DELIVERY FORM

PROCEDURE PERFORMED

D.R. Nurse On Duty (Name and Signature)

(If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RIZZA E. BESA, RN,MN Clinical Coordinator Butuan Doctors College a. PRC no.:__ 0246613________ Valid until: _January 22, 2015 b. PNA no. ___16734_____ Valid Until: ___Lifetime__ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Noted by: JENNIFER H. ARANA, RN,MN Chair, Nursing Department Butuan Doctors College a. PRC no.:_0254651______ Valid until: March 28, 2013 b. PNA no.:__ 2012 - 058427____ Valid Until:__December 31, 2012_ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Approved by: PURITA R. ESCOBAR, RN,MAN,DM Dean, Butuan Doctors College a. PRC no.: 22566 Valid until: June 15, 2013 b. PNA no.: 26981 Valid Until: Lifetime c. ADPCN no.: ___11 - 008___ Valid until: December 2012 Date Signed: Time: __________ Degree: BSN, MA in Nursing, Doctor of Management

BUTUAN DOCTORS COLLEGE

J.C. AQUINO AVENUE, BUTUAN CITY Tel. No.(085)342-85-72; Fax No. (085)225-42-93 E-mail: registrar@butuandoctors.com.ph

IMMEDIATE NEWBORN CORD CARE in ___________________________________________________________________

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

Prepared by: Printed Name and Signature of Student _________________________________________

Date Performed and Time Started Patients INITIALS (only) Case Number
(not applicable for Birthing/Lying-In Clinics/Homes)

IMMEDIATE CARE OF THE NEWBORN FORM

Immediate Newborn Cord Care PERFORMED Indicate where performed e.g. D.R., Nursery, NICU, or Home

Nurse On Duty (Name and Signature)

(If Midwife on Duty, Signature Not Required)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: RIZZA E. BESA, RN,MN Clinical Coordinator Butuan Doctors College a. PRC no.:__ 0246613________ Valid until: _January 22, 2015 b. PNA no. ___16734_____ Valid Until: ___Lifetime__ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Noted by: JENNIFER H. ARANA, RN,MN Chair, Nursing Department Butuan Doctors College a. PRC no.:_0254651______ Valid until: March 28, 2013 b. PNA no.:__ 2012 - 058427____ Valid Until:__December 31, 2012_ Date Signed: Time: __________ Degree: BSN, Masters in Nursing

Approved by: PURITA R. ESCOBAR, RN,MAN,DM Dean, Butuan Doctors College a. PRC no.: 22566 Valid until: June 15, 2013 b. PNA no.: 26981 Valid Until: Lifetime c. ADPCN no.: ___11 - 008____ Valid until: December 2012 Date Signed: Time: __________ Degree: BSN, MA in Nursing, Doctor of Management