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    Mylene Corcilles Inocente
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    This document is a surgical scrub form used by nursing students at the University of San Carlos College of Nursing. It requires students to provide their name and signature, the date and time of the surgical procedure, the patient's initials, the procedure performed, the name and signature of the operating room nurse on duty, and the name and signature of the supervising clinical instructor. Spaces are also provided for the clinical coordinator and dean to note and approve the completed form.

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    MAJOR FORM

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    This document is a surgical scrub form used by nursing students at the University of San Carlos College of Nursing. It requires students to provide their name and signature, the date and time of the surgical procedure, the patient's initials, the procedure performed, the name and signature of the operating room nurse on duty, and the name and signature of the supervising clinical instructor. Spaces are also provided for the clinical coordinator and dean to note and approve the completed form.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    33 views2 pages

    Major Form

    Uploaded by

    Mylene Corcilles Inocente
    This document is a surgical scrub form used by nursing students at the University of San Carlos College of Nursing. It requires students to provide their name and signature, the date and time of the surgical procedure, the patient's initials, the procedure performed, the name and signature of the operating room nurse on duty, and the name and signature of the supervising clinical instructor. Spaces are also provided for the clinical coordinator and dean to note and approve the completed form.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    UNIVERSITY OF SAN CARLOS

    ODC Form 2A
    COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
    O.R. SCRUB FORM
    PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph
    PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

    SURGICAL SCRUB in CEBU CITY MEDICAL CENTER, N. BACALSO ST., CEBU CITY
    Hospital/ Home/ Lying-in Clinic, Municipality/ City/ Province

    Prepared by:

    Printed Name with Signature of Student: ____________________________________

    Date Performed and Patient’s INITIALS SURGICAL PROCEDURE O.R. Nurse On Duty SUPERVISED BY
    Time Started (only) PERFORMED (Name and Signature) Clinical Instructor
    (Name and Signature)
    Case Number

    Noted by: Laarne E. Pontillas, R.N., M.S.N., M.A.N. Approved by: Antonia F. Pascual, R.N., M.N., M.S.N.
    (Print Name and Signature) (Print Name and Signature)
    Clinical Coordinator, PRC I.D. No. 0190308 Valid Until June 22, 2011 Dean, PRC I.D. No. 0054229 Valid Until August 5, 2012
    Date document is signed ______________ Time ________________ Date document is signed ______________ Time ________________

    Please specify Highest Nursing Degree Earned Master of Science in Nursing Please specify Highest Nursing Degree Earned Master in Nursing

    Master of Arts in Nursing Master of Science in Nursing

    (STRICTLY NO DESIGNATES)

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