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España Boulevard, Sampaloc, Manila, Philippines 1015 Tel. No. 406-1611 Loc.8241 Telefax: 731-5738 Website

This document is a surgical scrub form from the University of Santo Tomas College of Nursing. It contains fields to record information about a surgical scrub performed in a hospital including the date, time, patient's initials, surgical procedure, operating room nurse on duty, and signatures of the supervising clinical instructor and student. Clinical and academic supervisors must also sign off approving the documented surgical scrub.

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Nyeam Nyeam
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42 views1 page

España Boulevard, Sampaloc, Manila, Philippines 1015 Tel. No. 406-1611 Loc.8241 Telefax: 731-5738 Website

This document is a surgical scrub form from the University of Santo Tomas College of Nursing. It contains fields to record information about a surgical scrub performed in a hospital including the date, time, patient's initials, surgical procedure, operating room nurse on duty, and signatures of the supervising clinical instructor and student. Clinical and academic supervisors must also sign off approving the documented surgical scrub.

Uploaded by

Nyeam Nyeam
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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UNIVERSITY OF SANTO TOMAS COLLEGE OF NURSING UST:A012-00-FO05

España Boulevard, Sampaloc, Manila, Philippines 1015 rev 02 08/12/16


Tel. No. 406-1611 loc.8241; Telefax: 731-5738; Website: http://www.ust.edu.ph ODC Form 2 A
Accredited by PACUCOA, Level IV Accredited Status OR Scrub Form Major

SURGICAL SCRUB in
Hospital, Municipality/City/Province
PREPARED BY:
Printed Name and Signature of Student

DATE Patient’s INITIAL Only SUPERVISED BY


PERFORMED SURGICAL PROCEDURE O.R. NURSE ON DUTY
Clinical Instructor
AND TIME CASE NUMBER PERFORMED Name and Signature
Name and Signature
STARTED

Noted by: Approved by:


(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D. No. Valid Until: ______ Dean, PRC I.D. No. _________________ Valid Until ____________
Date document is signed: ___________ Time: ______________________ Date document is signed: ________________ Time:______________
Please specify Highest Nursing Degree Earned: ______________________ Specify Highest Nursing Degree Earned: _______________________

(STRICTLY NO DESIGNATES)

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