UNIVERSITY OF CEBU BANILAD

COLLEGE OF NURSING
DRUG STUDY
Patient: _________________________________________ Age: _______
Hospital No: ____________________
Diagnosis: _______________________________________ Attending Physician: _______________________________
Drug Name

Dosage

Indication / Mechanism of Action

Adverse / Side Effects

Room No: ____________

Nursing Responsibilities

Rationale

Client Teaching

Student: _____________________________________________

UNIVERSITY OF CEBU BANILAD

COLLEGE OF NURSING
DRUG STUDY
Patient: _________________________________________ Age: _______
Hospital No: ____________________
Diagnosis: _______________________________________ Attending Physician: _______________________________
Type of Solution

Classification

Content

Mechanism of Action

Indications

Room No: ____________

Contraindications

How Supplied

Dose

Nursing Responsibilities

Student: _____________________________________________

UNIVERSITY OF CEBU BANILAD

Governor Cuenco Ave., Banilad, Cebu City Philippines
(032) 234-2460, (032) 233-888 loc. 104/(032) 231-8613 / ucbanilad_registrar@uc.edu.ph
Level II Third Reaccredited Status embodies in CHED Order No. )1.s.2005.valid up to April 2012
SURGICAL SCRUB in _____________________________________________________________
Hospital, Municipality / City / Province
Prepared by:
____________________________________________________
(Name with Signature of Student)
Date Performed
and
Time Started

Patient's Initial Only

Case Number

Noted by: ______________________________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D. _______________ Valid Until ______________
Date document is signed: ___________________ Time _________________
Please Specify Highest Nursing Degree Earned: _______________________

SURGICAL
PROCEDURE
PERFORMED

O.R. Nurse On Duty

(Name and Signature)

Noted by: _____________________________________________________

(Print Name and Signature)
Dean, PRC I.D. _______________ Valid Until ______________
Date document is signed: ___________________ Time _________________
Please Specify Highest Nursing Degree Earned: _______________________

SUPERVISED BY
Clinical Instructor
Name and Signature

UNIVERSITY OF CEBU BANILAD

Governor Cuenco Ave., Banilad, Cebu City Philippines
(032) 234-2460, (032) 233-888 loc. 104/(032) 231-8613 / ucbanilad_registrar@uc.edu.ph
Level II Third Reaccredited Status embodies in CHED Order No. )1.s.2005.valid up to April 2012
SURGICAL CIRCULATING in _____________________________________________________________
Hospital, Municipality / City / Province
Prepared by:
____________________________________________________
(Name with Signature of Student)
Date Performed
and
Time Started

Patient's Initial Only

Case Number

Noted by: ______________________________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D. _______________ Valid Until ______________
Date document is signed: ___________________ Time _________________
Please Specify Highest Nursing Degree Earned: _______________________

SURGICAL
PROCEDURE
PERFORMED

O.R. Nurse On Duty

(Name and Signature)

Noted by: _____________________________________________________

(Print Name and Signature)
Dean, PRC I.D. _______________ Valid Until ______________
Date document is signed: ___________________ Time _________________
Please Specify Highest Nursing Degree Earned: _______________________

SUPERVISED BY
Clinical Instructor
Name and Signature

UNIVERSITY OF CEBU BANILAD

Governor Cuenco Ave., Banilad, Cebu City Philippines
(032) 234-2460, (032) 233-888 loc. 104/(032) 231-8613 / ucbanilad_registrar@uc.edu.ph
Level II Third Reaccredited Status embodies in CHED Order No. )1.s.2005.valid up to April 2012
ACTUAL DELIVERY in _____________________________________________________________
Hospital / Home / Lying-In, Municipality / City / Province
Prepared by:
____________________________________________________
(Name with Signature of Student)
Date Performed
and
Time Started

Patient's Initials Only

Case Number
(not applicable for Birthing/ Lying-In
Clinics/Homes)

Noted by: ______________________________________________________

(Print Name and Signature)
Clinical Coordinator, PRC I.D. _______________ Valid Until ______________
Date document is signed: ___________________ Time _________________
Please Specify Highest Nursing Degree Earned: _______________________

PROCEDURE
PERFORMED

D.R. Nurse On Duty

(Name and Signature)
(If Midwife On Duty,
Signature Not Required)

SUPERVISED BY
Clinical Instructor
Name and Signature

Approved by: _____________________________________________________

(Print Name and Signature)
Dean, PRC I.D. _______________ Valid Until ______________
Date document is signed: ___________________ Time _________________
Please Specify Highest Nursing Degree Earned: _______________________