University of Perpetual Help Rizal-Calamba Campus: I. Major Operations

UNIVERSITY OF PERPETUAL HELP RIZAL-CALAMBA CAMPUS
Brgy. Paciano Rizal. Calamba City
BASED ON BOARD OF NURSING

RESOLUTION NO. 357 S – 2010
Name of Student: _______________________________________________________________________________________________________________________________________________
Name and Address of School:______________________________________________________________________________________________________________________________________
Accreditation Level (if any): ________________________________________________Year Granted: ____________________________________________________________________________
Date School/Program was Recognized: _______________________________________ Number: ______________________________ Year: ____________________________________________
First Course (if any): ______________________________________________________School Graduated from: ___________________________________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________Year Graduated (BSN Program): ____________________________________________________________
I. MAJOR OPERATIONS
Date of Case Operation Type of Name of Name of Name of O.R Signature
NO. Name Of Patient Diagnosis
Operation No. Performed Anesthesia Surgeon Hospital Scrub Nurse OR Scrub Nurse
1.
2.
3.
4.
5.
Prepared by: Concurred by: Supervised by: Noted by:
Signature over Printed Name of the Student Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Instructor Signature over Printed Name of Clinical Coordinator
Date Signed: _______________________________ Date Signed: _______________________________ Date Signed: _______________________________
Degree: ___________________________________ Degree: ___________________________________ Degree: ___________________________________
a. PRC No.: _____________ Valid Until: ______________ a. PRC No.: _____________Valid Until: _______________ a. PRC No.: _____________ Valid Until: ______________
b. PNA No.: _____________Valid Until: _______________ b. PNA No.: _____________Valid Until:_______________ b. PNA No.: _____________Valid Until: _______________
Approved by:
Concurred by: Concurred by:
Signature over Printed Name of Dean

Signature over Printed Name of Chief Nurse Signature over Printed Name of Chief Nurse Date Signed: _______________________________
Date Signed: _______________________________ Date Signed: _______________________________ Degree: ___________________________________
Degree: ___________________________________ Degree: ___________________________________ a. PRC No.: _____________ Valid Until: ______________
a. PRC No.: _____________ Valid Until: ______________ a. PRC No.: _____________ Valid Until: ______________ b. PNA No.: _____________Valid Until: _______________
b. PNA No.: _____________Valid Until: _______________ b. PNA No.: _____________Valid Until: _______________ c. ADPCN No.: ___________Valid Until: ______________

Name of Student: _______________________________________________________________________________________________________________________________________________
Date School/Program was Recognized: _______________________________________ Number: ______________________________ Year: ____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________Year Graduated (BSN Program): ____________________________________________________________
II. MINOR OPERATIONS

Date of Case Operation Type of Name of Name of Name of O.R Signature
NO. Name Of Patient Diagnosis
Operation No. Performed Anesthesia Surgeon Hospital Scrub Nurse OR Scrub Nurse
1.
2.
3.
4.
5.
Prepared by: Concurred by: Supervised by: Noted by:
a. PRC No.: _____________ Valid Until: ______________ a. PRC No.: _____________Valid Until: _______________ a. PRC No.: _____________ Valid Until: ______________
b. PNA No.: _____________Valid Until: _______________ b. PNA No.: _____________Valid Until:_______________ b. PNA No.: _____________Valid Until: _______________
Approved by:

a. PRC No.: _____________ Valid Until: ______________ a. PRC No.: _____________ Valid Until: ______________ b. PNA No.: _____________Valid Until: _______________
b. PNA No.: _____________Valid Until: _______________ b. PNA No.: _____________Valid Until: _______________ c. ADPCN No.: ___________Valid Until: ______________

Name of Student: _______________________________________________________________________________________________________________________________________________
Date School/Program was Recognized:______________________________________ Number:________________________________ Year:____________________________________________
Year of Admission in the Bachelor of Science in Nursing Program: _________________Year Graduated (BSN Program):______________________________________________________________
III. ACTUAL DELIVERIES

Duration Supervised by: (Printed name & Signature)
Case Name of Date of Time of Gender Name of Type Of
NO. Diagnosis Age of
No. Mother Delivery Delivery Of baby Hospital Delivery
Delivery Clinical Instructor OR/DR Supervisor
1.
2.
3.
4.
5.
Prepared by: Supervised by: Noted by:
Signature over Printed Name of the Student Signature over Printed Name of Clinical Instructor Signature over Printed Name of Clinical Coordinator
Date Signed: _______________________________ Date Signed: _______________________________
Degree: ___________________________________ Degree: ___________________________________
a. PRC No.: ____________Valid Until: ________________ a. PRC No.: _____________ Valid Until: ______________
b. PNA No.: ____________Valid Until: ________________ b. PNA No.: _____________Valid Until: _______________
Approved by:

a. PRC No.: ____________Valid Until: ________________ a. PRC No.: ____________Valid Until: ________________ b. PNA No.: _____________Valid Until: _______________
b. PNA No.: ____________Valid Until: ________________ b. PNA No.: ____________Valid Until: ________________ c. ADPCN No.: ___________Valid Until: ______________

Name of Student: _______________________________________________________________________________________________________________________________________________
IV. DELIVERIES ASSISTED

Duration Supervised by: (Printed name & Signature)
Case Name of Date of Time of Gender Name of Type Of
NO. Diagnosis Age of
No. Mother Delivery Delivery Of baby Hospital Delivery
Delivery Clinical Instructor OR/DR Supervisor
1.
2.
3.
4.
5.

Concurred by:
a. PRC No.: ____________Valid Until: ________________ a. PRC No.: ____________Valid Until: ________________ a. PRC No.: _____________ Valid Until: ______________
b. PNA No.: ____________Valid Until: ________________ b. PNA No.: ____________Valid Until: ________________ b. PNA No.: _____________Valid Until: _______________
Approved by:


Name of Student: _______________________________________________________________________________________________________________________________________________
V. CORD DRESSING
Gender SUPERVISED BY:
Case Date Name of Name of Name Of
NO. of Age Name and Signature of
No. Performed Baby Mother Hospital
Baby Qualified CI
1.
2.
3.
4.
5.

Concurred by:
a. PRC No.: ____________Valid Until: ________________ a. PRC No.: ____________Valid Until: ________________ a. PRC No.: _____________ Valid Until: ______________
b. PNA No.: ____________Valid Until: ________________ b. PNA No.: ____________Valid Until: ________________ b. PNA No.: _____________Valid Until: _______________
Approved by:


University of Perpetual Help Rizal-Calamba Campus: I. Major Operations

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UNIVERSITY OF PERPETUAL HELP RIZAL-CALAMBA CAMPUS

Brgy. Paciano Rizal. Calamba City

BASED ON BOARD OF NURSING

Prepared by: Concurred by: Supervised by: Noted by:

Signature over Printed Name of Dean

BASED ON BOARD OF NURSING

II. MINOR OPERATIONS

Prepared by: Concurred by: Supervised by: Noted by:

Signature over Printed Name of Dean

BASED ON BOARD OF NURSING

III. ACTUAL DELIVERIES

Prepared by: Supervised by: Noted by:

Signature over Printed Name of Dean

BASED ON BOARD OF NURSING

IV. DELIVERIES ASSISTED

Prepared by: Supervised by: Noted by:

Signature over Printed Name of Dean

BASED ON BOARD OF NURSING

Prepared by: Supervised by: Noted by:

Signature over Printed Name of Dean

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