Lc. Case Form - New 2009

LAGUNA COLLEGE
Member, PHILIPPINE ASSOCIATION of COLLEGES and UNIVERSITIES

CITY OF SAN PABLO, PHILIPPINES
TELEPHONE: (049) 562-8078 FAX: (049) 562-8077, www.lagunacollege.edu.ph
SURGICAL SCRUB IN
Hospital, Municipality/City/Province
Prepared by:
Name of Student Signature of Student
Patient’s Name SUPERVISED BY

Date Performed and PROCEDURE O.R. Nurse On Duty
Clinical Instructor
Time Started Case Number PERFORMED (Name only)
Name and Signature
Noted by: Noted by: Concurred by:
PRINT NAME AND SIGNATURE PRINT NAME AND SIGNATURE PRINT NAME AND SIGNATURE
Chief Nurse Chief Nurse Clinical Coordinator-Laguna College
PRC ID No: Valid Until: PRC ID No: PRC ID No:
PNA No: Valid Until: Valid Until: Valid Until:
Date Document is signed: Time: Date Document is signed: Time: Date Document is signed: Time:
Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned:
Noted by: Noted by: Approved by:
Chief Nurse Chief Nurse Dean, Nursing Department-Laguna College
PRC ID No: Valid Until: PRC ID No: PRC ID No: PNA No.:
PNA No: Valid Until: Valid Until: Valid Until: Valid Until
Date Document is signed: Time: Date Document is signed: Time: Please specify Highest Nursing Degree Earned:
Please specify Highest Nursing Degree Earned: Please specify Highest Nursing Degree Earned:
For deliveries performed in Lying-In and Homes, ONLY THE

CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN.
LAGUNA COLLEGE
MINOR IN
Prepared by:
Patient’s Name
Case Number SUPERVISED BY
Date Performed and PROCEDURE D.R. Nurse/Midwife on
(not applicable for Clinical Instructor
Time Started PERFORMED Duty (Name only)
Birthing/Lying-In Name and Signature
Clinics/Homes)
LAGUNA COLLEGE

LAGUNA COLLEGE
ACTUAL DELIVERY IN
Prepared by:
Patient’s Name
Clinics/Homes)
LAGUNA COLLEGE

LAGUNA COLLEGE
IMMEDIATE NEWBORN CORD CARE IN
Prepared by:
Patient’s Name
Clinics/Homes)
LAGUNA COLLEGE

LAGUNA COLLEGE
ASSISTED DELIVERY IN
Prepared by:
Patient’s Name
Clinics/Homes)

LAGUNA COLLEGE


Lc. Case Form - New 2009

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LAGUNA COLLEGE

Member, PHILIPPINE ASSOCIATION of COLLEGES and UNIVERSITIES

Patient’s Name SUPERVISED BY

Noted by: Noted by: Concurred by:

Noted by: Noted by: Approved by:

For deliveries performed in Lying-In and Homes, ONLY THE

Noted by: Noted by: Concurred by:

Noted by: Noted by: Approved by:

For deliveries performed in Lying-In and Homes, ONLY THE

Noted by: Noted by: Concurred by:

Noted by: Noted by: Approved by:

For deliveries performed in Lying-In and Homes, ONLY THE

IMMEDIATE NEWBORN CORD CARE IN

Noted by: Noted by: Concurred by:

Noted by: Noted by: Approved by:

For deliveries performed in Lying-In and Homes, ONLY THE

Noted by: Noted by: Concurred by:

Noted by: Noted by: Approved by:

For deliveries performed in Lying-In and Homes, ONLY THE

For deliveries performed in Lying-In and Homes, ONLY THE

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