ODC Form 4

LORMA COLLEGES D.R. IMMEDIATE

Carlatan, San Fernando City, La Union NEWBORN CORD CARE
FORM
Phone 888 2616 /fax: (072) 242-3628 /lorma.org
(ACSCU-AAI Level II Re-Accredited, August 31 2007-April 2012)

IMMEDIATE NEWBORN CORD CARE in Lorma Medical Center, Carlatan, City of San Fernando, La Union

Prepared by: Balgos, Zebeah Angela A. Signature of Student: _________________________

Student

Date Performed Patient’s Name

and Immediate Newborn Cord Care Performed D.R. Nurse/Midwife SUPERVISED BY
Time Started Case Number On Duty

April 09, 2010 Baby Girl Hortaliza Delivery Room Jennie N. Dela Cruz, RN
1:45am Jonalyn D. Padilla, RN, MAN (Thesis Writing I)

April 10, 2010 Baby Girl Santos Delivery Room Jennie N. Dela Cruz, RN
7:30pm Winckle Briones, RN, MAN (33 units)

April 10, 2010 Baby Girl de Vera Delivery Room Jennie N. Dela Cruz, RN
9:10pm Winckle Briones, RN, MAN (33 units)

Noted by: Marie Grace M. Nones Concurred by: OFELIA C. PULIDO

Clinical Coordinator Chief Nurse
PRC I.D No. 0165388 Valid Until : December 06,2011 PRC I.D No. 23699 Valid Until : October 28, 2012
PNA No. 015126 Valid Until : December 2010 PNA No.00943 Valid Until : Lifetime
Date document is signed: _________________________ Time __________________ ANSAP No. 205 Valid Until: Lifetime
Highest Nursing Degree Earned: MAN Date document is signed: _____________ Time: ____________________
Highest Nursing Degree Earned: MAN

Approved by: LUDIVINA D. MAGPALI

Dean
PRC I.D No. 0186484 Valid Until: August 5,2012
PNA No. 15945 Valid Until: Lifetime
ADPCN No. 347 Valid Until: Dec, 2011
Date document is signed: _________________________ Time
___________________ Highest Nursing Degree Earned: MAN

ODC Form 3
D.R. ASSIST FORM
 LORMA COLLEGES
Carlatan, San Fernando City, La Union
Phone 888 2616 /fax: (072) 242-3628 /lorma.org
(ACSCU-AAI Level II Re-Accredited, August 31 2007-April 2012)

ASSISTED DELIVERY in Lorma Medical Center, Carlatan, City of San Fernando, La Union

Prepared by: Balgos, Zebeah Angela A. Signature of Student: ________________________

Student

Date Performed PROCEDURE PERFORMED D.R. Nurse/Midwife SUPERVISED BY

and Patient’s Name On Duty
Time Started
Case Number

April 01, 2010 D.E.B. Normal Spontaneous Delivery Glorifina G. Dacumos, RN

6:19am 305858 Jonalyn D. Padilla, RN, MAN (Thesis Writing I)

April 02, 2010 R.F.N. Normal Spontaneous Delivery Glorifina G. Dacumos, RN

10:20am 30596 Winckle Briones, RN, MAN (33 units)

April 03, 2010 V.A.L. Normal Spontaneous Delivery Glorifina G. Dacumos, RN

2:41am 220545 Winckle Briones, RN, MAN (33 units)

Noted by: Marie Grace M. Nones Concurred by: OFELIA C. PULIDO

Clinical Coordinator Chief Nurse
PRC I.D No. 0165388 Valid Until : December 06,2011 PRC I.D No. 23699 Valid Until : October 28, 2012
PNA No. 015126 Valid Until : December 2010 PNA No.00943 Valid Until : Lifetime
Date document is signed: _________________________ Time __________________ ANSAP No. 205 Valid Until: Lifetime
Highest Nursing Degree Earned: MAN Date document is signed: _____________ Time: ____________________
Highest Nursing Degree Earned: MAN

Approved by: LUDIVINA D. MAGPALI

Dean
PRC I.D No. 0186484 Valid Until: August 5,2012
PNA No. 15945 Valid Until: Lifetime
ADPCN No. 347 Valid Until: Dec, 2011
Date document is signed: _________________________ Time
___________________ Highest Nursing Degree Earned: MAN

LORMA COLLEGES
Carlatan, San Fernando City, La Union
ODC Form 2
ACTUAL DELIVERY FORM
 Phone 888 2616 /fax: (072) 242-3628 /lorma.org
(ACSCU-AAI Level II Re-Accredited, August 31 2007-April 2012)

ACTUAL DELIVERY in Caba Medicare and Community Hospital, Caba, La Union

Prepared by: Balgos, Zebeah Angela A. Signature of Student: ________________________

Student
Patient’s Name
Date Performed PROCEDURE PERFORMED D.R. Nurse/Midwife SUPERVISED BY
and Case Number On Duty
Time Started
August 28, 2009 A.D.P. Normal Spontaneous Delivery Medy Maglaya, RN
9:48pm C-18045 Rhodora Rulloda, RN, MAN (27 units)

January 07, 2010 E.A.M. Normal Spontaneous Delivery Mary Grace Maglaya, RN
10:15pm C-19211 Rhodora Rulloda, RN, MAN (27 units)

August 28, 2009 V.O.D. Normal Spontaneous Delivery Medy Maglaya, RN

6:35pm C-18181 Rhodora Rulloda, RN, MAN (27 units)

September 20, 2009 M.S.R. Normal Spontaneous Delivery Medy Maglaya, RN

9:25am C-18583 Rhodora Rulloda, RN, MAN (27 units)

Noted by: Marie Grace M. Nones Concurred by: CHONA B. GACHALLAN

Clinical Coordinator Nurse IV, Nursing Service Department
PRC I.D No. 0165388 Valid Until : December 06,2011 PRC I.D No. 0175519 Valid Until : January 16, 2011
PNA No. 015126 Valid Until : December 2010 PNA No. 011383 Valid Until : October 31, 2010
Date document is signed: _________________________ Time __________________ Date document is signed: _____________ Time: ____________________
Highest Nursing Degree Earned: MAN Highest Nursing Degree Earned: MAN

Approved by: LUDIVINA D. MAGPALI

Dean
PRC I.D No. 0186484 Valid Until: August 5,2012
PNA No. 15945 Valid Until: Lifetime
ADPCN No. 347 Valid Until: Dec, 2011
Date document is signed: _________________________ Time
___________________ Highest Nursing Degree Earned: MAN

LORMA COLLEGES
Carlatan, San Fernando City, La Union
ODC Form 1 O.R.
Scrub Form Minor
 Phone 888 2616 /fax: (072) 242-3628 /lorma.org
(ACSCU-AAI Level II Re-Accredited, August 31 2007-April 2012)

SURGICAL SCRUB in Caba Medicare and Community Hospital, Caba, La Union

Prepared by: Balgos, Zebeah Angela A. Signature of Student: ________________________

Student
Patient’s Name
Date Performed PROCEDURE PERFORMED D.R. Nurse/Midwife SUPERVISED BY
and Case Number On Duty
Time Started
January 13, 2010 E.G.M. Bilateral Tubal Ligation Rolyn D. De Vera, RN
10:15am A-17274 Rhodora Rulloda, RN, MAN (27 units)

Noted by: Marie Grace M. Nones Concurred by: CHONA B. GACHALLAN

Clinical Coordinator Nurse IV, Nursing Service Department
PRC I.D No. 0165388 Valid Until : December 06,2011 PRC I.D No. 0175519 Valid Until : January 16, 2011
PNA No. 015126 Valid Until : December 2010 PNA No. 011383 Valid Until : October 31, 2010
Date document is signed: _________________________ Time __________________ Date document is signed: _____________ Time: ____________________
Highest Nursing Degree Earned: MAN Highest Nursing Degree Earned: MAN

Approved by: LUDIVINA D. MAGPALI

Dean
PRC I.D No. 0186484 Valid Until: August 5,2012
PNA No. 15945 Valid Until: Lifetime
ADPCN No. 347 Valid Until: Dec, 2011
Date document is signed: _________________________ Time
___________________ Highest Nursing Degree Earned: MAN