OUR LADY OF FATIMA UNIVERSITY

# 1 ESPERANZA ST. HILLTOP HEIGHTS LAGRO, QUEZON CITY

PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph
PACUCOA LEVEL II, APRIL 10, 2002
ACTUAL DELIVERY in ______________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province

Prepared by:
Printed Name and Signature of Student____________________________________________
Patient's INITIAL Only
Date Performed and
Time Started

Case Number
(not applicable for Birthing/Lying - in
Clinics/Homes)

Noted by: _____________________________________

MARISOL GARCIA MANIPOL RN, MAN
Clinical Coordinator, PRC I.D. No. 0296870 Valid Until:
PNA No: 013487 Valid Until:
Date document is signed: _______________ Time __________
Please specify Highest Nursing Degree Earned: BSN, MAN_

PROCEDURE
PERFORMED

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on duty,
Signature Not
Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: _________________________________

NELIA R. CAPULONG RN, RM, MAN
Dean, PRC I.D. No. 0041904 Valid Until: ________________
PNA No: 013487 Valid Until: _________________
ADPCN No. 0627 Valid Until: __________________
Date document is signed: _______________ Time _______
Please specify Highest Nursing Degree Earned: BSN, MAN

OUR LADY OF FATIMA UNIVERSITY

# 1 ESPERANZA ST. HILLTOP HEIGHTS LAGRO, QUEZON CITY
PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph
PACUCOA LEVEL II, APRIL 10, 2002
SURGICAL SCRUB in ______________________________________________________
Hospital/Home/Municipality/City/Province
Prepared by:
Printed Name and Signature of Student____________________________________________
Patient's INITIAL Only
Date Performed and
Time Started

Case Number

Noted by: _____________________________________

MARISOL GARCIA MANIPOL RN, MAN
Clinical Coordinator, PRC I.D. No. 0296870 Valid Until: ______________
PNA No: 013487 Valid Until: _____________
Date document is signed: _______________ Time __________
Please specify Highest Nursing Degree Earned: BSN, MAN_

SURGICAL PROCEDURE
PERFORMED

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: _________________________________

NELIA R. CAPULONG RN, RM, MAN
Dean, PRC I.D. No. 0041904 Valid Until: ______________
PNA No: 013487 Valid Until: ________________
ADPCN No. 0627 Valid Until: ________________
Date document is signed: _______________ Time _______
Please specify Highest Nursing Degree Earned: BSN, MAN

OUR LADY OF FATIMA UNIVERSITY

# 1 ESPERANZA ST. HILLTOP HEIGHTS LAGRO, QUEZON CITY
PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph
PACUCOA LEVEL II, APRIL 10, 2002
ACTUAL DELIVERY in ______________________________________________________
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student____________________________________________
Date Performed
and
Time Started

Patient's INITIAL Only

Case Number (not applicable for
Birthing/Lying-In Clinics/Homes)

Noted by: _____________________________________

MARISOL GARCIA MANIPOL RN, MAN
Clinical Coordinator, PRC I.D. No. 0296870 Valid Until: __________________
PNA No: 013487 Valid Until: _________________
Date document is signed: _______________ Time __________
Please specify Highest Nursing Degree Earned: BSN, MAN_

PROCEDURE
PERFORMED
ASSISTED DELIVERY

D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature Not
Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: _________________________________

NELIA R. CAPULONG RN, RM, MAN
Dean, PRC I.D. No. 0041904 Valid Until: ____________
PNA No: 013487 Valid Until: ______________
ADPCN No. 0627 Valid Until: ______________
Date document is signed: _______________ Time _______
Please specify Highest Nursing Degree Earned: BSN, MAN

OUR LADY OF FATIMA UNIVERSITY

# 1 ESPERANZA ST. HILLTOP HEIGHTS LAGRO, QUEZON CITY
PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph
PACUCOA LEVEL II, APRIL 10, 2002
SURGICAL SCRUB in ______________________________________________________
Hospital/Home/Municipality/City/Province
Prepared by:
Printed Name and Signature of Student____________________________________________
Patient's INITIAL Only
Date Performed
and
Time Started

SURGICAL PROCEDURE
PERFORMED

Case Number

Noted by: _____________________________________

MARISOL GARCIA MANIPOL RN, MAN
Clinical Coordinator, PRC I.D. No. 0296870 Valid Until: ________________
PNA No: 013487 Valid Until: __________________
Date document is signed: _______________ Time: __________
Please specify Highest Nursing Degree Earned: BSN, MAN_

O.R. Nurse On Duty

(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: _________________________________

NELIA R. CAPULONG RN, RM, MAN
Dean, PRC I.D. No. 0041904 Valid Until: _____________
PNA No: 013487 Valid Until: ______________
ADPCN No. 0627 Valid Until: ______________
Date document is signed: _______________ Time _______
Please specify Highest Nursing Degree Earned: BSN, MAN

OUR LADY OF FATIMA UNIVERSITY

# 1 ESPERANZA ST. HILLTOP HEIGHTS LAGRO, QUEZON CITY
PHONE NUMBER: (02) 930 3258, FAX: 418 0185, admissions@fatima.edu.ph
PACUCOA LEVEL II, APRIL 10, 2002
IMMEDIATE NEWBORN CORD CARE in ______________________________________________________
Hospital/Home/Lying In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student____________________________________________
Date Performed
and
Time Started

Patient's INITIAL Only

Case Number (not applicable for
Birthing/Lying-In Clinics/Homes)

Immediate Newborn Cord Care

PERFORMED
Indicate where performed e.g. D.R.,
Nursery, NICU or Home

Noted by: _____________________________________

MARISOL GARCIA MANIPOL RN, MAN
Clinical Coordinator, PRC I.D. No. 0296870 Valid Until: __________________
PNA No: 013487 Valid Until: __________________
Date document is signed: _______________ Time __________
Please specify Highest Nursing Degree Earned: BSN, MAN_

D.R. Nurse On Duty

(Name and Signature) (If Midwife on
Duty, Signature not required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: _________________________________

NELIA R. CAPULONG RN, RM, MAN
Dean, PRC I.D. No. 0041904 Valid Until: _____________
PNA No: 013487 Valid Until: __________________
ADPCN No. 0627 Valid Until: ______________
Date document is signed: _______________ Time _______
Please specify Highest Nursing Degree Earned: BSN, MAN