ODC Form 1C

CORD CARE FORM

UNIVERSIDAD DE MANILA
(formerly City College of Manila)
Palma St Cor Arroceros St Mehan Gardens, Manila

IMMEDIATE NEWBORN CORD CARE in _______________________________

Hospital/Home/ Lying-in Clinic/Municipality/City/Province

Prepared by:
Printed Name and Signature of Student ___________________________________

Patient’s INITIAL Only

Date Performed Immediate Newborn Cord Care Nurse On Duty SUPERVISED BY
Case Number
and (not applicable for
PERFORMED (Name and Signature) Clinical Instructor
Indicate where performed e.g. D.R., (If Midwife on Duty,
Time Started Birthing Homes/ Lying-in
Nursery, NICU, or Home signature not required)
Name and Signature
Clinics/Homes)

Noted by:_______________________________ Approved by: __________________________________ ______

(Print Name and Signature) (Print Name and Signatur
Clinical Coordinator, PRC I.D. No. ___________ Valid Until ____________ Dean, PRC I.D. No. _______________ Valid Until __________
Date document is signed: ___________________Time _______________ Date document is signed: __________ Time: ______________
Please specify Highest Nursing Degree Earned: _____________________ Specify Highest Nursing Degree Earned: __________________