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Major Ni Allen 2

1) This document is an operating room scrub form from De La Salle Health Sciences Institute documenting four surgical procedures that a student participated in under supervision. 2) It lists the patient's initials, date, time, procedure performed, supervising nurse and clinical instructor for each case. 3) The form is signed by the student, clinical coordinator verifying participation, and dean approving the documentation.

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Zenon Saclayan
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65 views2 pages

Major Ni Allen 2

1) This document is an operating room scrub form from De La Salle Health Sciences Institute documenting four surgical procedures that a student participated in under supervision. 2) It lists the patient's initials, date, time, procedure performed, supervising nurse and clinical instructor for each case. 3) The form is signed by the student, clinical coordinator verifying participation, and dean approving the documentation.

Uploaded by

Zenon Saclayan
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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DE LA SALLE HEALTH SCIENCES INSTITUTE ODC Form 2A

Dasmariñas City, Cavite 4114, Philippines O.R. SCRUB FORM


(Cavite Line) 481-8000 (Manila Line) 988-3100, Fax (046) 481-8011
www.dlshsi.edu.ph Major
PAASCU Accredited – Level 2 November 28, 2008 – November 2013

SURGICAL SCRUB In De La Salle University Medical Center, Dasmariñas City, Cavite


Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student HUELGAS, JOHN ALLEN JARLOS _________________________

Date Performed Patient’s INITIALS only SUPERVISED BY


SURGICAL PROCEDURE O.R. Nurse On Duty
and Clinical Instructor
Case Number PERFORMED (Name and Signature)
Time Started Name and Signature

Sept. 15, 2009 E.L.


Apendectomy
7:51 am 86129 Ashleen R. Santos, RN Ejay H. Ignacio, RN, MAN

Dec. 1, 2009 T.M.A.


Adhesiolysis
12:30 pm 89253 Ashleen R. Santos, RN Ejay H. Ignacio, RN, MAN

April 28, 2010 N.R.


Superficial Parotidectomy Joanne Mariel R. Garcia,
8:05 am 95485 Ederlyn M. Taparan-Lumabi, RN, MAN
RN

Jan. 17, 2011 C.R.


Cholecystectomy
5:34 pm 107937 Ashleen R. Santos, RN Ederlyn M. Taparan-Lumabi, RN, MAN

Noted by: ________EDERLYN M. TAPARAN–LUMABI, RN, MAN__________ Approved by: _____NAOMI M. DE ARO, RN, MAN, EdD_______
(Printed Name and Signature) (Printed Name and Signature)
Clinical Coordinator, PRC I.D No. 0329074 Valid Until DECEMBER 28, 2013 Dean, PRC I.D No. 0186510 Valid Until OCTOBER 19, 2011
Date document is signed: Time ___ Date document is signed: Time
Please specify Highest Nursing Degree Earned: _________ MAN_________ Specify Highest Nursing Degree Earned: _________ EdD_______

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