Mindanao Sanitarium & Hospital College

Brgy. San Miguel, Iligan City 9200

Name of the Student: Jay G. Dela Cruz ________ ________________

Name & Address of School: Mindanao Sanitarium and Hospital College, Brgy. San Miguel, Iligan City 9200 ____ School code: 1362_________________________________________
Accreditation Level: Level 1 Year Granted: February 28, 2008
Date School Program was Recognized: October 17, 2002 Number: _0043 Year: 2002
First Course (If any):_None_ School Graduated From: Not Applicable Year: Not Applicable
Year of Admission in the Bachelor of Science in Nursing Program: 2007
Year Graduated from the BSN Program: 2011

II. MINOR OPERATIONS

Signature of
Operation Type of Name of O.R. Scrub
NO. Date of Operation Case No. Name of Patient Diagnosis Name of Surgeon Name of Hospital O.R. Scrub
Performed Anesthesia Nurse
Nurse
Complete Fracture of Distal Kolambugan
1 March 22, 2010 0013282 Leonesia Monfil End of Radius, Left Long Arm Casting Local Dr. Gleen Fuentes Judy Matutes Yap, RN
Provincial Hosptial

Mindanao
2 April 25, 2010 0608 Anthony Macapoy Phimosis Circumcision Local Dr. Edsel Cabaluna Sanitarium and Ritzel Orquillas, RN
Hospital

Mindanao
3 April 25, 2010 0609 Clinton Dumirao Phimosis Circumcision Local Dr. Edsel Cabaluna Ritzel Orquillas, RN
Sanitarium and
Hospital

Abnormal Bleeding Fractional Currettage, Mindanao

Secondary to Endocervical Cervical Polypectomy,
4 September 6, 2010 172595 Jane Clare Zarsuelo Spinal Dr. Ma. Lilagri Marcella Sanitarium and Ritzel Orquillas, RN
Polyp, Endometrial Gram Stain of Vaginal Hospital
Pathology Discharge

Lacerated Wound Lana0 Norte

5 September 20, 2010 018866 Ronel Comunsad Wound Suturing Local Dr. Enrico Maruhom Luz. Muňasque, RN
Provincial Hospital

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

___JAY G. DELA CRUZ______ ARMELYN GRACE M. MAGHANOY MAN, RN LUCY MAY L. BUCAYAN, MN, RN NOEMI T. MORENTE, MAN, RN DAILINA R. PERANG MN, RN TRANSFIGURACION C. LEE, MN, RN G’TER G. GAID, Ph.D, MAN, RN
Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name Signature Over Printed Name
Student Clinical Instructor Clinical Coordinator Nursing Service Director (MSH) Chief Nurse (KDH) Chief Nurse (LNPH) Dean

Date Signed: ____________
Date Signed: ___________ Date Signed:___________ Date Signed:___________ Date Signed:____________ Date Signed:____________ Date Signed:____________
a.) PRC No.: 0173884 a.) PRC No.: 0193232 a.) PRC No.: 0161458 a.) PRC: 091730 a.) PRC No.: 0059574 a.) PRC No.: 0302269
Valid Until: October 4, 2012 Valid Until: May 25, 2013 Valid Until: October 1, 2011 Valid Until: July 12, 2011 Valid Until: August 6, 2011 Valid Until: September 13, 2012
b.) PNA No.: 15658 b.) PNA No.: 035664 b.) PNA No.: 15898 b.) PNA No: 018082 b.) PNA: 13935 b.) PNA No: 16832
Valid Until: Lifetime Valid Until: October 31, 2011 Valid Until: Lifetime Valid Until: December 2011 Valid Until: Lifetime Valid Until: Lifetime
c.) ANSAP No.: 090900 c.) ANSAP No.: 01863 c.) ANSAP No: 0513 c.) ADPCN No.: 0768
Valid Until: January 1, 2012 Valid Until: December 31, 2011 Valid Until: Lifetime Valid Until: 2011