DE LOS SANTOS-STI COLLEGE, INC ODC Form 2A

201 E. Rodriguez Sr. Blvd., Quezon City OR SCRUB FORM

Major

SURGICAL SCRUB in De Los Santos –STI Medical Center

Hospital/ Municipality/City/Province

Prepared by:
Printed Name and Signature of Student : Dulay, Bea Kristine S.

Date Performed SUPERVISED BY

Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature
LRM
February 24, 2010 Anterior Cruciate Ligament,
10-02240013
4:15 pm Reconstruction Right Knee Mr. Enclid C. Ruiz, RN Mrs. Dee Dee A. Lucido, RN,MAN
721-78-71/721-78-87/721-7877/ 722-06-27

(Print Name and Signature) (Print Name and Signature)

Noted by: MR. ROMEO G. SAÑO, R.N., M.A.N Approved by: MS. NORIELEE S. MAGSINGIT, R.N., M.A.N
Clinical Coordinator, PRC I.D No 243835 Valid Until December 7, 2013 Dean, PRC I.D. No 162291 Valid Until April 6, 2011
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: R.N., M.A.N Specify Highest Nursing Degree Earned: R.N., M.A.N

(STRICTLY NO DESIGNATES)
 DE LOS SANTOS-STI COLLEGE, INC ODC Form 2A
201 E. Rodriguez Sr. Blvd., Quezon City OR SCRUB FORM
721-78-71/721-78-87/721-7877/ 722-06-27 Major
SURGICAL SCRUB in Calalang General Hospital, Valenzuela City
Hospital/ Municipality/City/Province

Prepared by:
Printed Name and Signature of Student : Dulay, Bea Kristine S.

Date Performed SUPERVISED BY

Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

RA
June 24, 2009 Low Transverse Caesarian
091096
2:30 pm Section
Ms. Joy Molina RN Mrs. Vicky M. Parlan, RN,MAN

(Print Name and Signature) (Print Name and Signature)

Noted by: MR. ROMEO G. SAÑO, R.N., M.A.N Approved by: MS. NORIELEE S. MAGSINGIT, R.N., M.A.N
Clinical Coordinator, PRC I.D No 243835 Valid Until December 7, 2013 Dean, PRC I.D. No 162291 Valid Until April 6, 2011
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: R.N., M.A.N Specify Highest Nursing Degree Earned: R.N., M.A.N
(STRICTLY NO DESIGNATES)

ODC Form 2A
OR SCRUB FORM
Major
 DE LOS SANTOS-STI COLLEGE, INC
201 E. Rodriguez Sr. Blvd., Quezon City
721-78-71/721-78-87/721-7877/ 722-06-27

SURGICAL SCRUB in Quezon City General Hospital_______

Hospital/ Municipality/City/Province

Prepared by:
Printed Name and Signature of Student Dulay, Bea Kristine S.___

Date Performed SUPERVISED BY

Patient's INITIAL Only SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature
August 10, 2009 E.N
6:10 pm 825355 Left herniography Jocelyn Chavez, RN Benita D. J. Torres, RN, MAN
August 12, 2009 A.N
3:38 pm 825513 Thoracotomy Removal Maricar Ramores, RN Benita D. J. Torres, RN, MAN
August 17, 2009 L.L
6:27 pm 805656 Thyroidectomy Jocelyn Chavez, RN Benita D. J. Torres, RN, MAN

(Print Name and Signature) (Print Name and Signature)

Noted by: MR. ROMEO G. SANO, R.N., M.A.N Approved by: MS. NORIELEE S. MAGSINGIT, R.N., M.A.N
Clinical Coordinator, PRC I.D No 243835 Valid Until December 07, 2013 Dean, PRC I.D. No 162291 Valid Until April-2011
Date document is signed: Time Date document is signed: Time
Please specify Highest Nursing Degree Earned: R.N., M.A.N Specify Highest Nursing Degree Earned: R.N., M.A.N

(STRICTLY NO DESIGNATES)