General guidelines for signing of templates:

1. Mount all your case slips in long bond paper . Chronologically arranged.
2. Accomplish templates (see samples below). Take note of the following:
a. 1 template per institution; if cases were all accomplish in 1 institution, you can put all cases in one template aslong as it can be accommodated in 1 page.
If not then make another template.
b. There are no case numbers for the following: ITR well baby, cases taken at ER,OPR,Minor OR of hospitals and community cases and medical-surgical
mission cases. The college takes the responsibility of forwarding the certification to PRC that these cases do not bear any case number. Therefore, there
is no need for you to get certification from the different institutions.
c. For medical mission cases, the CI supervising signs both item for CI and Staff nurse.
d. For cases accomplished during completion duty at slu and bmc without a CI, Mrs. Cherrylina Dalilis’ is place at the item CI and signs for that case.
e. Cases are to be written in chronological order. First case to latest.

3. Proceed with the processing of signing of your templates by the CI and staff nurses.
4. Safe keep all accomplished templates.
 ODC Form 1A
ACTUAL DELIVERY FORM

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600
Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48
Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/
CHED Recognition: Government Resolution #41 S. 1980
Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU)
Level 2 valid up to 2010

ACTUAL DELIVERY in: Abra Provincial Hospital, Bangued, Abra

Hospital, Municipality, Province

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed Supervised by:

D.R. Nurse On Duty Clinical Instructor
And Patient’s Initials PROCEDURE PERFORMED
Name and Signature Name and Signature
Time Started
Case Number

02-13-10 A.B. Estrella Leviste, RN

Normal Spontaneous Delivery Marie Jane Bernardez, RN
2:46 PM 892490

Noted by: RUFINA C. ABUL Approved by: MARY GRACE C. LACANARIA

Department Head LEVEL IV, SLU College of Nursing Dean, SLU College of Nursing
Master of Arts in Nursing (MAN) Master of Science in Nursing (MSN)
PRC I.D. No. 0176104 Valid until: 11-21-2011 Doctor of Philosophy in Education (PhD)
PNA No. 13302 Valid until: LIFETIME PRC I.D. No.0126255 Valid until: 11-10-2013
Date signed: _______________ Time: ______________ PNA No: 9860 Valid until: LIFETIME
ADPCN No: 275 Valid until: 12-31-2011
Date signed: __________________ Time: ______________

Note:
For Home delivery: Actual Delivery in: Lengaoan, Buguias, Benguet (Home Delivery)
Community, Municipal, Province
 ODC Form 1B
ASSISTED DELIVERY FORM

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600
Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48
Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/
CHED Recognition: Government Resolution #41 S. 1980
Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU)
Level 2 valid up to 2010

ASSISTED DELIVERY in: Ilocos Training and Regional Medical Center, City of San Fernando, La Union
Hospital, City, Province

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed Supervised by:

PROCEDURE PERFORMED D.R. Nurse On Duty Clinical Instructor
And Patient’s Initials
ASSISTED DELIVERY Name and Signature Name and Signature
Time Started
Case Number

12-12-09 A. P. Charmaine Co, RN

Normal Spontaneous Delivery Roni Joyce Novillero, RN
11:10 PM 2009-0030928

12-27-09 G. A. Blas Blasil Purganan, RN

Normal Spontaneous Delivery Marjorie Navalta,RN
2:40 PM 2009-0031553

Noted by: RUFINA C. ABUL Approved by: MARY GRACE C. LACANARIA

Department Head LEVEL IV, SLU College of Nursing Dean, SLU College of Nursing
Master of Arts in Nursing (MAN) Master of Science in Nursing(MSN)
PRC I.D. No. 0176104 Valid until: 11-21-2011 Doctor of Philosophy in Education (PhD)
PNA No. 13302 Valid until: LIFETIME PRC I.D. No.0126255 Valid until: 11-10-2013
Date signed: _______________ Time: ______________ PNA No: 9860 Valid until: LIFETIME
ADPCN No: 275 Valid until: 12-31-2011
Date signed: __________________ Time: ______________
 ODC Form 1C
CORD CARE FORM

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600
Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48
Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/
CHED Recognition: Government Resolution #41 S. 1980
Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU)
Level 2 valid up to 2010

IMMEDIATE NEWBORN CORD CARE in: Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, City

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed Supervised by:

Immediate Newborn Cord Care Nurse On Duty Clinical Instructor
And Patient’s Initials
PERFORMED Name and Signature Name and Signature
Time Started
Case Number

04-28-09 B.B.P. Felda Ibasitas, RN

Cord Care - Nursery Wendy Villareal, RN
9:30 PM PB363215
 ODC Form 2A
O.R. SCRUB FORM
Major

Noted by: RUFINA C. ABUL Approved by: MARY GRACE C. LACANARIA

Department Head LEVEL IV, SLU College of Nursing Dean, SLU College of Nursing
Master of Arts in Nursing (MAN) Master of Science in Nursing(MSN)
PRC I.D. No. 0176104 Valid until: 11-21-2011 Doctor of Philosophy in Education (PhD)
PNA No. 13302 Valid until: LIFETIME PRC I.D. No.0126255 Valid until: 11-10-2013
Date signed: _______________ Time: ______________ PNA No: 9860 Valid until: LIFETIME
ADPCN No: 275 Valid until: 12-31-2011
Date signed: __________________ Time: ______________

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600
Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48
Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/
CHED Recognition: Government Resolution #41 S. 1980
Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU)
Level 2 valid up to 2010

SURGICAL SCRUB in: Benguet General Hospital, La Trinidad, Benguet

Hospital, Municipality, Province

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed Supervised by:

O.R. Nurse On Duty Clinical Instructor
And Patient’s Initials SURGICAL PROCEDURE PERFORMED
Name and Signature Name and Signature
Time Started
Case Number
 06-09-09 S.D. Emergency Low Segment Cesarean Section and Genevieve Pablito, RN
Frederick Gabriel, RN
4:27 PM 241175 Bilateral Tubal Ligation

Noted by: RUFINA C. ABUL Approved by: MARY GRACE C. LACANARIA

Department Head LEVEL IV, SLU College of Nursing Dean, SLU College of Nursing
Master of Arts in Nursing (MAN) Master of Science in Nursing(MSN)
PRC I.D. No. 0176104 Valid until: 11-21-2011 Doctor of Philosophy in Education (PhD)
PNA No. 13302 Valid until: LIFETIME PRC I.D. No.0126255 Valid until: 11-10-2013
Date signed: _______________ Time: ______________ PNA No: 9860 Valid until: LIFETIME
ADPCN No: 275 Valid until: 12-31-2011
Date signed: __________________ Time: ______________
 ODC Form 2B
O.R. MINOR FORM
SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600
Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48
Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/
CHED Recognition: Government Resolution #41 S. 1980
Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU)
Level 2 valid up to 2010

SURGICAL SCRUB in: Baguio Medical Center, Baguio City

Hospital, City

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed Supervised by:

O.R. Nurse On Duty Clinical Instructor
And Patient’s Initials SURGICAL PROCEDURE PERFORMED
Name and Signature Name and Signature
Time Started
Case Number

04-14-09 J.G. Lawrence Gayo, RN

Cervical Biopsy and Diagnostic Dilation and Curettage Chiara Rene Barcelo, RN
3:05 PM 11711434

10-21-09 M. D. Cherylina Dalilis, RN

Excision of Lipoma Maria Olivia Daag, RN
10:34 AM 442

Noted by: RUFINA C. ABUL Approved by: MARY GRACE C. LACANARIA

Department Head LEVEL IV, SLU College of Nursing Dean, SLU College of Nursing
Master of Arts in Nursing (MAN) Master of Science in Nursing(MSN)
PRC I.D. No. 0176104 Valid until: 11-21-2011 Doctor of Philosophy in Education (PhD)
PNA No. 13302 Valid until: LIFETIME PRC I.D. No.0126255 Valid until: 11-10-2013
Date signed: _______________ Time: ______________ PNA No: 9860 Valid until: LIFETIME
ADPCN No: 275 Valid until: 12-31-2011
Date signed: __________________ Time: ______________

Note: if case was accomplished in a medical mission:pls follow the ff format for title
 ODC Form 2C
O.R. CIRCULATING
SURGICAL SCRUB in: Sanitary Camp Health Center, Baguio City (Medical Mission sponsored by Rotary Club of Baguio)
Barangay, City, Sponsoring Agency

SAINT LOUIS UNIVERSITY

College of Nursing, Baguio City, 2600
Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48
Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/
CHED Recognition: Government Resolution #41 S. 1980
Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU)
Level 2 valid up to 2010

O.R. CIRCULATING in: Baguio Medical Center Baguio City

Hospital, City

Prepared by: QUITALIG, ELVIS DE LA RAGA

Date Performed Supervised by:

O.R. Nurse On Duty Clinical Instructor
And Patient’s Initials SURGICAL PROCEDURE PERFORMED
Name and Signature Name and Signature
Time Started
Case Number

06-16-09 R. B. Lawrence Gayo, RN

Completion Curettage Vannesa Canillas, RN
3:35 PM 11711440

Noted by: RUFINA C. ABUL Approved by: MARY GRACE C. LACANARIA

Department Head LEVEL IV, SLU College of Nursing Dean, SLU College of Nursing
Master of Arts in Nursing (MAN) Master of Science in Nursing(MSN)
PRC I.D. No. 0176104 Valid until: 11-21-2011 Doctor of Philosophy in Education (PhD)
PNA No. 13302 Valid until: LIFETIME PRC I.D. No.0126255 Valid until: 11-10-2013
Date signed: _______________ Time: ______________ PNA No: 9860 Valid until: LIFETIME
ADPCN No: 275 Valid until: 12-31-2011
Date signed: __________________ Time: ______________