UNIVERSITY OF ILOILO

Rizal Street, Iloilo City D.R Form 1B

Tel No. (033) 338-1071 Loc. 146 ASSISTED DELIVERY
FORM

ASSISTED DELIVERY IN ____WESTERN VISAYAS MEDICAL CENTER,MANDURIAO/ ILOILO CITY/ ILOILO

Hospital/Home/Lying-in Clinic/Municipality/City/Province

Prepared by:
Printed Name and Signature of Student:____PRINCESS ESTANTE MELLIZA / .

Date Performed Patient’s INITIAL only D.R NURSE ON DUTY Supervised by:
and PROCEDURE PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
Time Started Case Number If Midwife on Duty (Name and Signature)
(Not Applicable for Signature not Required
Birthing/Lying-in Clinics/Homes

September 3, 2018 . T.B.G . Normal Spontaneous Vaginal Delivery Kathrine R. Salarda R.N Ana Rowena A. Perera R.N
5:08 pm 815196 M.A.N

September 14, 2018 . V.B.B . Normal Spontaneous Vaginal Delivery Kathrine R. Salarda R.N Ana Rowena A. Perera R.N
3:17 pm 818289 M.A.N

November 12, 2018 . S.B.B . Normal Spontaneous Vaginal Delivery Kathrine R. Salarda R.N Ana Rowena A. Perera R.N
7:06 am 829455 M.A.N

JANE P. MILABO, R.N., M.A.N.

Noted by:___________________________________________________________ MARIE JOYCE J. SIMPAS, R.N., M.A.N.
Approved by: _________________________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.:__0135750__ Valid Until: __JUNE 24, 2021__ Dean, PRC I.D No.:_ 0232266___ Valid Until: __ NOVEMBER 28 , 2021__
Date document is signed: ___________________Time:______________________ Date document is signed: ________________Time:___________________
Please specify highest Nursing Degree Earned:______M.A.N__________________ Please specify highest Nursing Degree Earned:_________M.A.N_________
 UNIVERSITY OF ILOILO
Rizal Street, Iloilo City D.R Form 1B
Tel No. (033) 338-1071 Loc. 146 ASSISTED DELIVERY
FORM

ASSISTED DELIVERY IN ____WESTERN VISAYAS MEDICAL CENTER,MANDURIAO/ ILOILO CITY/ ILOILO

Hospital/Home/Lying-in Clinic/Municipality/City/Province

Prepared by:
Printed Name and Signature of Student:____PRINCESS ESTANTE MELLIZA / .

Date Performed Patient’s INITIAL only D.R NURSE ON DUTY Supervised by:
and PROCEDURE PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
Time Started Case Number If Midwife on Duty (Name and Signature)
(Not Applicable for Signature not Required
Birthing/Lying-in Clinics/Homes

February 25, 2018 . F.B.B . Normal Spontaneous Vaginal Delivery Kathrine R. Salarda R.N Ana Rowena A. Perera R.N
3:52 pm 780719 M.A.N

February 24, 2018 . L.B.G . Normal Spontaneous Vaginal Delivery Kathrine R. Salarda R.N Ana Rowena A. Perera R.N
10:01 am 850334 M.A.N

JANE P. MILABO, R.N., M.A.N.

Noted by:___________________________________________________________ MARIE JOYCE J. SIMPAS, R.N., M.A.N.
Approved by: _________________________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.:__0135750__ Valid Until: __JUNE 24, 2021__ Dean, PRC I.D No.:_ 0232266___ Valid Until: __ NOVEMBER 28 , 2021__
Date document is signed: ___________________Time:______________________ Date document is signed: ________________Time:___________________
Please specify highest Nursing Degree Earned:______M.A.N__________________ Please specify highest Nursing Degree Earned:_________M.A.N_________
 UNIVERSITY OF ILOILO
Rizal Street, Iloilo City ODC Form 28
Tel No. (033) 338-1071 Loc. 146 O.R CIRCULATING FORM

SURGICAL SCRUB IN ____WESTERN VISAYAS MEDICAL CENTER,MANDURIAO/ ILOILO CITY/ ILOILO

Hospital/Home/Lying-in Clinic/Municipality/City/Province

Prepared by:
Printed Name and Signature of Student:____PRINCESS ESTANTE MELLIZA / .

Date Performed Patient’s INITIAL only O.R NURSE ON DUTY Supervised by:
and PROCEDURE PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
Time Started Case Number (Name and Signature)

January 21, 2019 . S.C.J . Transacral Primary Endorectal pull through Jorwin L. Badana, R.N Ana Rowena A. Perera R.N
8:55 am 830790 with Frozen section Biospsy M.A.N

JANE P. MILABO, R.N., M.A.N.

Noted by:___________________________________________________________ MARIE JOYCE J. SIMPAS, R.N., M.A.N.
Approved by: _________________________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.:__0135750__ Valid Until: __JUNE 24, 2021__ Dean, PRC I.D No.:_ 0232266___ Valid Until: __ NOVEMBER 28 , 2021__
Date document is signed: ___________________Time:______________________ Date document is signed: ________________Time:___________________
Please specify highest Nursing Degree Earned:______M.A.N__________________ Please specify highest Nursing Degree Earned:_________M.A.N_________
 UNIVERSITY OF ILOILO
Rizal Street, Iloilo City ODC Form 28
Tel No. (033) 338-1071 Loc. 146 O.R CIRCULATING FORM

SURGICAL SCRUB IN ____WESTERN VISAYAS MEDICAL CENTER,MANDURIAO/ ILOILO CITY/ ILOILO

Hospital/Home/Lying-in Clinic/Municipality/City/Province

Prepared by:
Printed Name and Signature of Student:____PRINCESS ESTANTE MELLIZA / .

Date Performed Patient’s INITIAL only O.R NURSE ON DUTY Supervised by:
and PROCEDURE PERFORMED (Name and Signature) CLINICAL INSTRUCTOR
Time Started Case Number (Name and Signature)

January 22, 2019 . C.M.P . Excision of Fibroeithelial Tumor Jim Joseph D. Barba, R.N Ana Rowena A. Perera R.N
9:00 am 837932 Fasciocutaneous Rotational Flap, JP Drain M.A.N

JANE P. MILABO, R.N., M.A.N.

Noted by:___________________________________________________________ MARIE JOYCE J. SIMPAS, R.N., M.A.N.
Approved by: _________________________________________________
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.:__0135750__ Valid Until: __JUNE 24, 2021__ Dean, PRC I.D No.:_ 0232266___ Valid Until: __ NOVEMBER 28 , 2021__
Date document is signed: ___________________Time:______________________ Date document is signed: ________________Time:___________________
Please specify highest Nursing Degree Earned:______M.A.N__________________ Please specify highest Nursing Degree Earned:_________M.A.N_________