ODC Form 1 O.R.

SCRUB FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: uphsgma_nursing@yahoo.com, Website: uphsl.edu.ph

SURGICAL SCRUB in __________________________________________________________________ Hospital, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

Date Performed and Time Started

Patients Name Case Number

PROCEDURE PERFORMED

O.R. Nurse On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Chief Nurse

PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

Concurred by:

____ Clinical Coordinator

____

PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

Dean PRC I.D No. Valid Until PNA No. Valid until________________________ ADPCN No. Valid Until Date document is signed: Time____________________ Please specify Highest Nursing Degree Earned:_______________________________________________________________________________

ODC Form 2 ACTUAL DELIVERY

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: uphsgma_nursing@yahoo.com, Website: uphsl.edu.ph

ACTUAL DELIVERY in __________________________________________________________________ Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

Date Performed and Time Started

Patients Name Case Number

(Not applicable for Birthing/Lying-In Clinics/Homes)

PROCEDURE PERFORMED

O.R. Nurse / Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Chief Nurse

PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

Concurred by:

____ Clinical Coordinator

____

PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

Dean PRC I.D No. Valid Until PNA No. Valid until_________________________ ADPCN No. Valid Until Date document is signed: Time____________________ Please specify Highest Nursing Degree Earned:_______________________________________________________________________________

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN

ODC Form 3 D.R. ASSIST FORM

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: uphsgma_nursing@yahoo.com, Website: uphsl.edu.ph

ASSISTED DELIVERY in __________________________________________________________________ Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

Date Performed and Time Started

Patients Name Case Number

(Not applicable for Birthing/Lying-In Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse / Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Chief Nurse

PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

Concurred by:

____ Clinical Coordinator

____

PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

Dean PRC I.D No. Valid Until PNA No. Valid until_________________________ ADPCN No. Valid Until Date document is signed: Time____________________ Please specify Highest Nursing Degree Earned:_______________________________________________________________________________

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN

UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS

BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
PHONE #:(02)490-7748, Fax #: (046)890-1393, Email Add: uphsgma_nursing@yahoo.com, Website: uphsl.edu.ph

ODC Form 4 D.R. IMMEDIATE NEWBORN

IMMEDIATE NEWBORN CORD CARE in __________________________________________________________________ Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

Date Performed and Time Started

Patients Name 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

D.R. Nurse / Midwife On Duty (Name only)

SUPERVISED BY Clinical Instructor Name and Signature

Noted by: Chief Nurse

PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

Concurred by:

____ Clinical Coordinator

____

PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

Dean PRC I.D No. Valid Until PNA No. Valid until_________________________ ADPCN No. Valid Until Date document is signed: Time____________________ Please specify Highest Nursing Degree Earned:_______________________________________________________________________________

For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN