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OUR LADY OF FATIMA UNIVERSITY

#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

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_____________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________
Year Graduated (BSN Program):_____________________________________________________________________________________________

I. Major Operations
No. Date of Case Name of Patient Diagnosis Operation Type of Name of Name of Supervised by Signature of
Operation No. Performed Anesthesia Surgeon Hospital Qualified CI Qualified CI
1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Approved by:


_________________
Signature over printed Name of Student _____________________ _________________________ Nelia R. Capulong, RN, MAN
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ a.) PRC NO: ___________
Date Signed: ____________ b.) PRC NO: __________ a.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
a.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

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_____________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________
Year Graduated (BSN Program):_____________________________________________________________________________________________

II. Minor Operations


No. Date of Case No. Name of Patient Diagnosis Operation Type of Name of Surgeon Name of Hospital Supervised by Signature of
Operation Performed Anesthesia Qualified CI Qualified CI
1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Approved by:


_________________
Signature over printed Name of Student _____________________ _________________________ Nelia R. Capulong, RN, MAN
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ b.) PRC NO: ___________
Date Signed: ____________ d.) PRC NO: __________ b.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
c.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

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_____________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________
Year Graduated (BSN Program):_____________________________________________________________________________________________

III. Actual Deliveries


No. Case Diagnosis Name of Age Date of Time of Gender Name of Type of Delivery Supervised by:
No. Mother Delivery Delivery of Baby Hospital Signature of Qualified
C.I.
1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Approved by:


_________________
Signature over printed Name of Student _____________________ _________________________ Nelia R. Capulong, RN, MAN
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ c.) PRC NO: ___________
Date Signed: ____________ f.) PRC NO: __________ c.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
e.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

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_____________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________
Year Graduated (BSN Program):_____________________________________________________________________________________________

IV. Deliveries Assisted


No. Case No. Diagnosis Name of Age Date of Time of Gender of Name of Hospital Type of Delivery Supervised by:
Mother Delivery Delivery Baby Signature of
Qualified C.I.
1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Approved by:


_________________
Signature over printed Name of Student _____________________ _________________________ Nelia R. Capulong, RN, MAN
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ d.) PRC NO: ___________
Date Signed: ____________ h.) PRC NO: __________ d.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
g.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________
OUR LADY OF FATIMA UNIVERSITY
#1 Esperanza St. Hilltop Mansion Heights, Lagro, Quezon City

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_____________________
Year of Admission in the Bachelor of Science in Nursing Program: __________________________________________________________________
Year Graduated (BSN Program):_____________________________________________________________________________________________

V. Cord Dressing
No. Case No. Date Name of Baby Gender of Name of Mother Age Name of Hospital Supervised by: Signature of
Performed Baby Qualified C.I.
1.

2.

3.

4.

5.

Prepared by: Noted by: Concurred by: Approved by:


_________________
Signature over printed Name of Student _____________________ _________________________ Nelia R. Capulong, RN, MAN
Signature over printed name of Clinical Signature over printed name of Signature over printed name of Dean
Supervised by: Coordinator Chief Nurse Date Signed: ____________
_______________ Date Signed: __________ Date Signed: ___________ Degree:________________
Signature over printed name of Faculty Degree:_______________ Degree:_______________ e.) PRC NO: ___________
Date Signed: ____________ j.) PRC NO: __________ e.) PRC NO: __________ Valid Until: __________
Degree: ________________ Valid Until: ________ Valid Until: ____________ b.) PNA NO: ____________
i.) PRC NO: __________ b.) PNA NO: ___________ b.) PNA NO: ___________ Valid Until: __________
Valid Until: ________ Valid Until:_________ Valid Until: _________ c.) ADPCN NO:_________
b.) PNA NO: ___________ Valid Until: ___________
Valid Until:_________

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