PRC Form of New Curri (Odc Form 1a)

ODC Form 1A
ACTUAL DELIVERY
FORM
Our Lady of Fatima University

Esperanza St., Hilltop Mansion, Lagro, Quezon City
ACTUAL DELIVERY in
_____________________________________________________________________________________
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student______________________________________________________________________________________________________
Date Performed
And
Time Started
Patients INITIAL Only

______________________
Case Number
D.R. Nurse On Duty

(Name and Signature)
(If Midwife on Duty,
Signature not
required)
PROCEDURE
PERFORMED
(not applicable for

Birthing/Lying-In
Clinics/Homes)
Noted by:
(
Printed Name and Signature

Clinical Coordinator
PRC I.D. No.: __________ Valid Until:
_________
PNA I.D. No.: _________ Valid Until:
__________
Date document is signed: ______ Time: ____
Concurred by:
)

Chief Nurse of the Hospital
SUPERVISED BY
Clinical Instructor
Name and Signature
Concurred by:
)

Approved by:
(
)
Dean
PRC I.D. No.: _________ Valid Until: ________
PRC I.D. No.: ________ Valid Until: ________
PRC I.D. No.: ______ Valid Until: _________
PNA I.D. No.: ________ Valid Until: ________
PNA I.D. No.: _______ Valid Until: ________
PNA I.D. No.: _____ Valid Until: _________
Date document is signed: _____ Time: _____
Date document is signed: ____ Time: _____
Please specify Highest Nursing Degree

Earned:
__________________________________

Earned:
_________________________________

Earned:
____________________________________

Earned:
ODC Form 1B
___________________________________
ASSISTED DELIVERY
FORM
(STRICTLY NO DESIGNATES)

ASSISTED DELIVERY in
_________________________________________________________________________________
Prepared by:
Printed Name and Signature of Student___________________________________________________________________________________________________
Concurred
Date Performed
Patients INITIAL
Only by:
PROCEDURE
Noted by:
AndName and Signature
______________________
(
Printed
)
(
Printed Name and
Signature
)
PERFORMED
Time Started
Case Number
Clinical Coordinator (not applicable for Chief Nurse of the Hospital

ASSISTED DELIVERY
Lying-In
PRC I.D. No.: __________ ValidBirthing/
Until:
PRC
I.D. No.: _________ Valid Until: ________
Clinics/Homes)
_________
__________
Date document is signed: ______ Time:
_______
Earned:
Earned:
__________________________________
_________________________________
Concurred
by:Nurse
D.R.
(
On Duty
(Name
and
Signature)
(If Midwife on Duty,
Chief Nurse
of required)
the Hospital
Signature
not
Approved by:
)
PRC I.D. No.: ________ Valid Until: ________
BY
( SUPERVISED
Printed Name
and Signature
Clinical
Instructor
)
Dean
Name and Signature
PRC I.D. No.: ________ Valid Until: _________
PNA I.D. No.: _______ Valid Until: ________
PNA I.D. No.: ________ Valid Until: _________
Date document is signed: ____ Time:

________
Earned:
___________________________________

Earned:
____________________________________
ODC Form 1C
CORD CARE FORM
IMMEDIATE NEWBORN CORD CARE in

______________________________________________________________________
Prepared by:
Printed Name and Signature of Student_________________________________________________________________________________________________
Noted by:
Concurred
by:
Concurred by:
Patients INITIAL
Only
Immediate Newborn Cord
Date
Performed
Nurse
On
Duty
(
Printed
Name and Signature
(
Printed
Name
and
Signature
(
Printed Name
and
Signature
______________________
Care
)
)
)
And
Case Number
PERFORMED
Clinical
Coordinator
Chief (If
Nurse
of the Hospital
Time
Started
Midwife
on Duty,
(not applicable for
Indicate where performed
PRC I.D. No.: _________ Valid Until:
PRC I.D. No.:
________
Valid
Until:
Signature not required)
Birthing Homes/Lying-in
e.g. D.R, Nursery, ________
_________
________
Clinics/Homes)
NICU,
or________
Home PNA I.D. No.: _______ Valid Until:
PNA I.D. No.: ________ Valid
Until:
__________
________
Approved by:
SUPERVISED
BY Signature
(
Printed Name and
)
Clinical Instructor
Dean
Name and Signature
PRC I.D. No.: ______ Valid Until:
_________
Date document is signed: ______

Time: ____
Please specify Highest Nursing
Degree Earned:
Date document is signed: _____

Time: _____
Degree Earned:

Time: _____
Degree Earned:

___
Degree Earned:
__________________________________
_________________________________
____________________________________
___________________________________
ODC Form 2A
O.R. SCRUB FORM

Major
SURGICAL SCRUB in ___________________________________________________________________________________

Prepared by:
Printed Name and Signature of Student________________________________________________________________________________________________
Noted by:
Concurred by:
( DatePrinted
Performed
Name and Signature
Patients INITIALS
(
)
And
(only))
Coordinator______________________
TimeClinical
Started
PRC
I.D.
No.: _________ Valid Until:
Case Number
_________
________
__________
Approved by:
(
SUPERVISED
Printed Name BY
and Signature
)
Clinical Instructor
Dean
Name and Signature
_________
Date document is signed: ______

Time: ____
Degree Earned:

Time: _____
Degree Earned:
Concurred by:
(
Printed
O.R.
Name
Nurse
and Signature
On Duty
)
PRC I.D. No.: ________ Valid Until:
________
PNA I.D. No.: _______ Valid Until:
________

Time: _____
Degree Earned:

___
Degree Earned:
__________________________________
_________________________________
____________________________________
___________________________________
SURGICAL
PROCEDURE
PERFORMED
ODC Form 2B
O.R. CIRCULATING
FORM
CIRCULATING ___________________________________________________________________________
HospitaL, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student_____________________________________________________________________________________________
Concurred by:
Noted
Dateby:
Performed
Patients INITIALS
(
Printed
(
And Name and SignatureOnly
) Time Started
)
______________________
Clinical CoordinatorCase Number
PRC I.D. No.: _________ Valid Until:
_________
________
__________
Date document is signed: ______ Time:
Date document is signed: _____ Time:
____
_____
Earned:
Earned:
__________________________________
_________________________________
Concurred by:
SURGICAL PROCEDURE
(
)
PERFORMED
O.R. Nurse On Duty

Printed
Signature
(NameName
and and
Signature)

PRC I.D. No.: ________ Valid Until:
________
PNA I.D. No.: _______ Valid Until:
________
Date document is signed: _____ Time:
_____
Earned:
____________________________________
Approved by:
SUPERVISED BY
( Clinical
Printed
Name and Signature
Instructor
)Name and Signature
Dean
_________
_____
Earned:
___________________________________

PRC Form of New Curri (Odc Form 1a)

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PRC Form of New Curri (Odc Form 1a)

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ODC Form 1A

Our Lady of Fatima University

Patients INITIAL Only

D.R. Nurse On Duty

(not applicable for

Printed Name and Signature

Printed Name and Signature

Printed Name and Signature

PRC I.D. No.: _________ Valid Until: ________

PRC I.D. No.: ________ Valid Until: ________

PRC I.D. No.: ______ Valid Until: _________

PNA I.D. No.: ________ Valid Until: ________

PNA I.D. No.: _______ Valid Until: ________

PNA I.D. No.: _____ Valid Until: _________

Date document is signed: _____ Time: _____

Date document is signed: _____ Time: _____

Date document is signed: ____ Time: _____

Please specify Highest Nursing Degree

Please specify Highest Nursing Degree

Please specify Highest Nursing Degree

Please specify Highest Nursing Degree

Our Lady of Fatima University

Clinical Coordinator (not applicable for Chief Nurse of the Hospital

PRC I.D. No.: ________ Valid Until: ________

PNA I.D. No.: _______ Valid Until: ________

PNA I.D. No.: ________ Valid Until: _________

Date document is signed: _____ Time: _____

Date document is signed: ____ Time:

Please specify Highest Nursing Degree

IMMEDIATE NEWBORN CORD CARE in

Date document is signed: ______

Date document is signed: _____

Date document is signed: _____

Date document is signed: ____ Time:

O.R. SCRUB FORM

SURGICAL SCRUB in ___________________________________________________________________________________

Date document is signed: ______

Date document is signed: _____

Date document is signed: _____

Date document is signed: ____ Time:

O.R. Nurse On Duty

Chief Nurse of the Hospital

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PRC I.D. No.: _ Valid Until:

PRC I.D. No.: Valid Until:

PRC I.D. No.: Valid Until: ___

PNA I.D. No.: Valid Until:

PNA I.D. No.: _ Valid Until: __

PNA I.D. No.: _ Valid Until: _____

Date document is signed: _ Time: _

Date document is signed: _ Time: _

Date document is signed: Time: _

PRC I.D. No.: Valid Until:

PNA I.D. No.: _ Valid Until: __

PNA I.D. No.: Valid Until: _

Date document is signed: _ Time: _