University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 2A O.R. SCRUB FORM Major

SURGICAL MAJOR in GOVERNOR CELESTINO GALLARES MEMORIAL HOSPITAL- TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started June 25, 2009 7:23 pm April 29, 2010 4:22 pm June 18, 2010 5:41 pm Patients INITIALS Case Number 072679 - JJAS 101987-2010 AAS 121657-2010 FCA SURGICAL PROCEDURE PERFORMED Exploratory Laparotomy, Adhesiolysis, Appendectomy, Lavage Emergency Repeat Cesarian Section with Bilateral Tubal Ligation Shortening Osteotomy Right Ulna O.R. Nurse on Duty SUPERVISED BY CLINICAL INSTRUCTOR

PURIFICACION L. PIQUERO, BSNRN KARENE MARIE B. CALUNOD, BSN-RN ELIZABETH R. REYES, BSN-RN

LALAINE L. DOMAPIAS, BSNRN, MAN ROSSINI C. BIRAD, BSN-RN, MAN ROSSINI C. BIRAD, BSN-RN, MAN

Noted by: CASILDA C. LAPEZ, BSN-RN, MAN BSN-RN, MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 November 16, 2012 Date document is signed: _________________ Time: ____________ Please specify Highest Nursing Degree Earned: BSN,MAN

Approved by:

ISABELITA G. MARGATE, Valid Until

Dean, PRC I.D No. 0131064

Date document is signed: _____________ Time: ___________ Please specify Highest Nursing Degree Earned: BSN,MAN

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 2A O.R. SCRUB FORM Major

SURGICAL MAJOR in RAMIRO COMMUNITY HOSPITAL - TAGBILARAN CITY, BOHOL

Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started July 23, 2009 8:30 am Patients INITIALS Case Number SURGICAL PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY CLINICAL INSTRUCTOR

09-5021 - AAR

Total Abdominal Hysterectomy with Bilateral Salpingo Oophorectomy with Appendectomy Debridement, Open Reduction Cerclage Wiring Right Proximal Femur

LEONIDO A. FUNCHICA III, BSN-RN

MAIA KRISTINE G. MARGATE,BSN RN

May 13, 2010 9:50 pm

10-3426 - ALM

JUDEE D. BAGUIO, BSN- RN

ROSETTE M. GARCIA, BSN-RN

Noted by: CASIL DA C. L APEZ , BSN- RN , M AN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9, 2013 16, 2012 Date document is signed: _________________ Time: _____________ Please specify Highest Nursing Degree Earned: BSN,MAN

Approved by: ISABEL ITA G. M ARGATE, BSN - RN , M AN Dean, PRC I.D No. . 0131064 Valid Until November Date document is signed:________________ Time: ______________ Please specify Highest Nursing Degree Earned: BSN,MAN

University of Bohol COLLEGE OF NURSING City of Tagbilaran Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 2B O.R. SCRUB FORM Minor

SURGICAL MINOR in GOVERNOR CELESTINO GALLARES MEMORIAL HOSPITAL- TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started November 13, 2008 3:52 pm September 3, 2009 1: 48 am December 17, 2009 2:08 pm Patients INITIALS Case Number 4870 - DLC 078230 - RMB 92378-2009 - IDP SURGICAL PROCEDURE PERFORMED Removal of Toe Nails Suturing O.R. Nurse on Duty EVELYN C. MICABALO, BSNRN HECTOR C. RODRIGUEZ, BSN-RN, MAN SUPERVISED BY CLINICAL INSTRUCTOR ZENAIDA R. BUENCONSEJO, BSN-RN, MAN FLORDELIZA J. LUMANTAS, BSN RN, MAN

Suturing

JOSEPH R. REDULLA, BSN-RN

ELEAZAR D. LANZADERAS, BSN-RN

June 17, 2010 9: 30 pm

121861-2010 - ETO

Emergency Repair of Corneal Laceration (Left Eye)

MARIA NADINE A. LAGURA, BSN-RN

Approved by:

ROSSINI C. BIRAD, BSN-RN, MAN

Noted by:

CASIL DA C. L APEZ , BSN- RN , M AN

ISABEL ITA G. M ARGATE, BSN - RN , M AN

Coordinator, PRC I.D No.: 0066642 Valid Until : April 9, 2013 16, 2012 Date document is signed: ___________________ Time: ____________ Please specify Highest Nursing Degree Earned: BSN,MAN

Dean, PRC I.D No. . 0131064

Valid Until November

Date document is signed: ___________________ Time: _____________ Please specify Highest Nursing Degree Earned: BSN,MAN

University of Bohol COLLEGE OF NURSING City of Tagbilaran Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 2B O.R. SCRUB FORM Minor

SURGICAL MINOR in RAMIRO COMMUNITY HOSPITAL - TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started

Patients INITIALS Case Number 10-3411 - PBG

SURGICAL PROCEDURE PERFORMED Arterio- Venous Shunt Insertion Right

O.R. Nurse on Duty

SUPERVISED BY CLINICAL INSTRUCTOR

May 13, 2010 6:48 pm

ALONA B. ARSENA, BSN-RN

ROSETTE M. GARCIA, BSN-RN

Noted by: CASIL DA C. L APEZ , BSN- RN , M AN Coordinator, PRC I.D No.: 0066642 Valid Until 16, 2012

: April 9, 2013

Approved by: ISABEL ITA G. M ARGATE, BSN - RN , M AN Dean, PRC I.D No. . 0131064 Valid Until November

Date document is signed: ___________________ Time: ____________ Please specify Highest Nursing Degree Earned: BSN,MAN

Date document is signed: ___________________ Time: _____________ Please specify Highest Nursing Degree Earned: BSN,MAN

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

University of Bohol COLLEGE OF NURSING City of Tagbilaran

ODC Form 1B ASSISTED DELIVERY FORM

ASSISTED DELIVERY in GOVERNOR CELESTINO GALLARES MEMORIAL HOSPITAL- TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Delivered October 15, 2009 2:15 pm October 17, 2009 3:47 pm April 8, 2010 8:12 pm Patients INITIALS Case Number 82697-2009 - MHC 82811-2009 - JOL PROCEDURE PERFORMED Assisted Delivery Assisted Delivery Nurse on Duty SUPERVISED BY CLINICAL INSTRUCTOR VERLITA T. CUADRA,BSNRN,MAN, PhD VERLITA T. CUADRA,BSNRN,MAN, PhD VERLITA T. CUADRA,BSNRN,MAN, PhD

CERLITA D. BALO, BSN-RN FLORA S. MANIGQUE, BSNRN ARLENE A. BONGCAYO, BSN-RN

110177-2010 - LBG

Assisted Delivery

January 28, 2011 11:32 am

155658-2010 - GTG

Assisted Delivery

MARCELA P. PARAISO, BSNRN

MELINDA C. PAUSANOS,BSNRN,MAN

Noted by: CASILDA C. LAPEZ, BSN-RN, MAN Approved by: ISABELITA G. MARGATE, BSN-RN, MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9, 2013 Dean, PRC I.D No. . 0131064 Valid Until November 16, 2012 Date document is signed: ________________ Time : ____________ Date document is signed: ________________ Time : ___________ Please specify Highest Nursing Degree Earned: BSN,MAN Please specify Highest Nursing Degree Earned: BSN,MAN

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 1A
ACTUAL DELIVERY FORM

ACTUAL DELIVERY in GOVERNOR CELESTINO GALLARES MEMORIAL HOSPITAL- TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started October 16, 2009 4:11 am Patients INITIALS Case Number 82784-2009 - LSA PROCEDURE PERFORMED Nurse on Duty SUPERVISED BY CLINICAL INSTRUCTOR

Handled Delivery

CORA G. GARAY, BSN-RN

VERLITA T. CUADRA,BSNRN,MAN, PhD

October 23, 2009 9:56 am

83967-2009 - BOB

Handled Delivery

CERLITA D. BALO, BSN-RN

VERLITA T. CUADRA,BSNRN,MAN, PhD

Noted by: CASIL DA C. L APEZ , BSN - RN , M AN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 16, 2012 Date document is signed: ___________________ Time: _____________ Please specify Highest Nursing Degree Earned: BSN, MAN

Approved by: ISABEL ITA G. M ARGATE, BSN - RN , M AN Dean, PRC I.D No. 0131064 Valid Until November Date document is signed: _________________ Time: _______________ Please specify Highest Nursing Degree Earned: BSN,MAN

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

University of Bohol COLLEGE OF NURSING City of Tagbilaran

ODC Form 1C CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in GOVERNOR CELESTINO GALLARES MEMORIAL HOSPITAL- TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Delivered October 16, 2009 6:23 am Patients INITIALS Case Number 82786-2009 - JPB CORD CARE Nurse on Duty SUPERVISED BY CLINICAL INSTRUCTOR VERLITA T. CUADRA,BSNRN,MAN, PhD

Delivery Room

CORA G. GARAY, BSN-RN

October 22, 2009 6:21 am April 8, 2010 11:36 pm

83776-2009 - JAT 110177-2010 - CAC

Delivery Room Delivery Room

MARCELA P. PARAISO, BSNRN ARLENE A. BONGCAYO, BSN-RN

VERLITA T. CUADRA,BSNRN,MAN, PhD VERLITA T. CUADRA,BSNRN,MAN, PhD

Noted by: CASILDA C. LAPEZ, BSN-RN, MAN Approved by: ISABELITA G. MARGATE, BSN-RN, MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9, 2013 Dean, PRC I.D No. . 0131064 Valid Until November 16, 2012 Date document is signed: ________________ Time : ____________ Date document is signed: ________________ Time : ___________ Please specify Highest Nursing Degree Earned: BSN,MAN Please specify Highest Nursing Degree Earned: BSN,MAN

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 1A ACTUAL DELIVERY FORM

ACTUAL DELIVERY in RAMIRO COMMUNITY HOSPITAL - TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started PROCEDURE PERFORMED SUPERVISED BY CLINICAL INSTRUCTOR

Patients INITIALS Case Number

Nurse on Duty

May 15, 2010 12:03 am

10-3668 - SCP

Handled Delivery

ALONA B. ARSENA, BSN-RN

ROSETTE M. GARCIA, BSN-RN

Noted by: CASIL DA C. L APEZ , BSN - RN , M AN Approved by: ISABEL IT A G. M ARGATE, BSN- RN , MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 Dean, PRC I.D No. 0131064 Valid November 16, 2012 Date document is signed: ____________________ Time: ______________ Date document is signed: __________________ Time: ________________ Please specify Highest Nursing Degree Earned: BSN, MAN Please specify Highest Nursing Degree Earned: BSN,MAN

Until

ODC Form 1A

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ACTUAL DELIVERY FORM

ACTUAL DELIVERY in INTEGRATED MIDWIVES ASSOCIATION OF THE PHILPPINES LYING-IN, TAGBILARAN CITY, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed Patients INITIALS PROCEDURE SUPERVISED BY

and Time Started May 6, 2010 2:27 pm

Case Number

PERFORMED

Midwife on Duty

CLINICAL INSTRUCTOR

2264 - GGC

Handled Delivery

CORAZON L. PARAS, RM

IVY L. CALCABEN, BSN-RN

Noted by: CASIL DA C. L APEZ , BSN - RN , M AN Approved by: ISABEL IT A G. M ARGATE, BSN- RN , MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 Dean, PRC I.D No. 0131064 Valid November 16, 2012 Date document is signed: ____________________ Time: ______________ Date document is signed: __________________ Time: ________________ Please specify Highest Nursing Degree Earned: BSN, MAN Please specify Highest Nursing Degree Earned: BSN,MAN

Until

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 1A ACTUAL DELIVERY FORM

ACTUAL DELIVERY in CONGRESSMAN SIMEON TORIBIO MEMORIAL HOSPITAL- CARMEN, BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed and Time Started January 7, 2010 5:47 am

Patients INITIALS Case Number 64885 - MCI

PROCEDURE PERFORMED

Nurse on Duty

SUPERVISED BY CLINICAL INSTRUCTOR

Handled Delivery

RICARDA P. MEBRANO, BSN-RN

EMMA RUBY D. GOYENECHE, BSN-RN, MAN

Noted by: CASIL DA C. L APEZ , BSN - RN , M AN Approved by: ISABEL IT A G. M ARGATE, BSN- RN , MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 Dean, PRC I.D No. 0131064 Valid November 16, 2012 Date document is signed: ____________________ Time: ______________ Date document is signed: __________________ Time: ________________ Please specify Highest Nursing Degree Earned: BSN, MAN Please specify Highest Nursing Degree Earned: BSN,MAN

Until

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 1C CORD CARE FORM

IMMEDIATE NEWBORN CORD CARE in TEODORO B. GALAGAR DISTRICT HOSPITAL-JAGNA BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed Patients INITIALS CORD CARE Nurse on Duty SUPERVISED BY

and Time Started August 28, 2010 1:55 am September 4, 2010 2:37 am

Case Number 068683 - JAS Delivery Room AGUSTINA B. BAYOCOT, BSN-RN

CLINICAL INSTRUCTOR LOIS JOAN S. NAMOCATCAT, BSN-RN, MAN

068822 - JDN

Delivery Room

AGUSTINA B. BAYOCOT, BSN-RN

LOIS JOAN S. NAMOCATCAT, BSN-RN, MAN

Noted by: CASIL DA C. L APEZ , BSN - RN , M AN Approved by: ISABEL IT A G. M ARGATE, BSN- RN , MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 Dean, PRC I.D No. 0131064 Valid November 16, 2012 Date document is signed: ____________________ Time: ______________ Date document is signed: __________________ Time: ________________ Please specify Highest Nursing Degree Earned: BSN, MAN Please specify Highest Nursing Degree Earned: BSN,MAN

Until

University of Bohol COLLEGE OF NURSING City of Tagbilaran

Ma. Clara St., Tagbilaran City Bohol, Philippines Phone No.: (038) 411-3484/ Fax No.: (038) 411-3101 (Government Recognition No. 60, s. 1980)

ODC Form 1B ASSISTED DELIVERY FORM

ASSISTED DELIVERY in MANSASA BARANGAY HEALTH CENTER, TAGBILARAN CITY ,BOHOL Prepared by:

MARK JOHNUEL M. DUAVIS

Date Performed Patients INITIALS PROCEDURE SUPERVISED BY

and Time Started August 28, 2010 10:08 am

Case Number 0010 - GMG

PERFORMED Assisted Delivery

Nurse on Duty ERLINDA S. BOJO, BSNRN

CLINICAL INSTRUCTOR MA. CONSUELO C. FORMILLEZA, BSNRN, MAN

Noted by: CASIL DA C. L APEZ , BSN - RN , M AN Approved by: ISABEL IT A G. M ARGATE, BSN- RN , MAN Clinical Coordinator, PRC I.D No.: 0066642 Valid Until: April 9,2013 Dean, PRC I.D No. 0131064 Valid November 16, 2012 Date document is signed: ____________________ Time: ______________ Date document is signed: __________________ Time: ________________ Please specify Highest Nursing Degree Earned: BSN, MAN Please specify Highest Nursing Degree Earned: BSN,MAN

Until