UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

Operating Room Form

(Major and Minor)

Delivery Room Form

(Delivery. Assist, and Cord Care)
 ODC Form 2A
O.R. SCRUB FORM major
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY

Hospital/ Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
SUPERVISED BY
Date Performed and Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty Clinical Instructor
Time Started Case Number PERFORMED (Name AND Signature) Name and Signature

F.A. Primary Low Segment

November 26,2009 – 6:47PM 65139-09 Transverse Caesarian Section Mrs. Rowena M. Escasinas Ms. Melinda Rabutin
R.C.L. Lobectomy Right,
July 26,2010 – 9:30 AM 166907 Isthmusectomy Mrs. Rowena M. Escasinas Dr. Betty Lynn C. Garingo
D.G.B. Cystoscopy, Cystolithotripsy
July 27,2010 – 10:50 AM 161740 Ms. Florence N. Juntilla Dr. Betty Lynn C. Garingo
F.D.M.C. Herniorrhapy Mesh Repair
July 27,2010 – 1:30 PM 160179 Mrs. Lilibeth L. Punay Dr. Betty Lynn C. Garingo
G.B.D. Appendectomy
July 30,2010 – 8:55 AM 169131 Mrs. Rowena M. Escasinas Dr. Betty Lynn C. Garingo

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN
ODC Form 2B
(STRICTLY NO DESIGNATES)
O.R. CIRCULATING FORM
Republic of the Philippines
 Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in VICENTE GULLAS MEDICAL CENTER/BANILAD/MANDAUE CITY

Hospital/ Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
SUPERVISED BY
Date Performed and Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty Clinical Instructor
Time Started Case Number PERFORMED (Name AND Signature) Name and Signature

D.T.M. Debridement
November 27,2009 – 4:00 PM 01-0334 Ms. Lenie M. Sombilon Mr. Phillip Mark Bueno

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 2B
O.R. CIRCULATING FORM
Republic of the Philippines

Professional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in LAPU-LAPU DISTRICT HOSPITAL/LAPU-LAPU CITY

Hospital/ Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
SUPERVISED BY
Date Performed and Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty Clinical Instructor
Time Started Case Number PERFORMED (Name AND Signature) Name and Signature

R.P.B. Suturing
January 26,2010 – 7:30 PM 2010-266 Mrs. Gina Gollez Menguito Mr. Wilson B. Maxilom

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 2B
O.R. CIRCULATING FORM
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
SUPERVISED BY
Date Performed and Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty Clinical Instructor
Time Started Case Number PERFORMED (Name AND Signature) Name and Signature

J.S.A. Episiorraphy
October 13,2010 10-10017 Ms. Teresita Y. Sayson Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 2B
O.R. CIRCULATING FORM
Republic of the Philippines
 Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

SURGICAL SCRUB in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY

Hospital/ Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL
SUPERVISED BY
Date Performed and Patient’s INITIAL only SURGICAL PROCEDURE O.R. Nurse on Duty Clinical Instructor
Time Started Case Number PERFORMED (Name AND Signature) Name and Signature

S.N.P. Excision Biopsy

August 25,2009 – 9:05 AM 65937 - 2009 Mrs. Preciosa V. Borinaga Mrs. Josephine A. Alo

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)

ODC Form 1A
Actual Delivery Form
Republic of the Philippines
Professional Regulation Commission
 Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in GRENGIA MATERNITY HOUSE/LAPU-LAPU

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
Time Started Case Number (Name AND Signature) Clinical Instructor
(not applicable for Birthing (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) required)
A.A. Normal Spontaneous Vaginal
December 09,2009 – 1:51 PM 1599-2009 Delivery Dr. Josephus Grengia Mrs. Loida B. Alondres

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1A
Actual Delivery Form
Republic of the Philippines

Professional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in EVERSLY CHILD SANITARIUM/JAGOBIA/CEBU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
Time Started Case Number (Name AND Signature) Clinical Instructor
(not applicable for Birthing (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) required)
S.G. Normal Spontaneous Vaginal
January 29,2010 – 10:15 AM 085249 Delivery Ms. Jasmin A. Pepito Mrs. Loida B. Alondres

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1A
Actual Delivery Form
Republic of the Philippines

Professional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only PROCEDURE PERFORMED O.R. Nurse on Duty SUPERVISED BY
Time Started Case Number (Name AND Signature) Clinical Instructor
(not applicable for Birthing (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) required)
S.O.T. Normal Spontaneous Vaginal
October 14, 2010 – 1:43 PM 10-10090 Delivery Mrs. Teresita Y. Sayson Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1B
ASSISTED Delivery Form
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only PROCEDURE PERFORMED D.R. Nurse on Duty SUPERVISED BY
Time Started Case Number (Name AND Signature) Clinical Instructor
(not applicable for Birthing ASSISTED DELIVERY (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) required)
A.D. Normal Spontaneous Vaginal
July 10,2009 – 1:20 AM 55622-2009 Delivery Mrs. Nelpha B. Obordo Mrs. Ma. Flor L. Operario

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1B
ASSISTED Delivery Form
Republic of the Philippines

Professional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in EVERSLY CHILD SANITARIUM/JAGOBIA/CEBU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only PROCEDURE PERFORMED D.R. Nurse on Duty SUPERVISED BY
Time Started Case Number (Name AND Signature) Clinical Instructor
(not applicable for Birthing ASSISTED DELIVERY (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) required)
A.T. Normal Spontaneous Vaginal
January 25,2010 – 9:50 AM 024950 Delivery Ms. Jasmin A. Pepito Mrs. Loida B. Alondres

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1B
ASSISTED Delivery Form
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

ACTUAL DELIVERY in MANDAUE CITY HOSPITAL/MANDAUE CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only PROCEDURE PERFORMED D.R. Nurse on Duty SUPERVISED BY
Time Started Case Number (Name AND Signature) Clinical Instructor
(not applicable for Birthing ASSISTED DELIVERY (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) required)
Z.T.N. Normal Spontaneous Vaginal
May 12,2010 – 9:44 PM 13832-A Delivery Mrs. Ma. Georgia Lada Mr. Sergio Valiente

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1C
CORD CARE FORM
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in VICENTE SOTTO MEMORIAL MEDICAL CENTER/CEBU CITY
Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only Immediate Newborn Cord Nurse on Duty SUPERVISED BY
Time Started Case Number Care PERFORMED (Name AND Signature) Clinical Instructor
(not applicable for Birthing Indicate where performed e.g. D.R., (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) Nursery, NICU, or Home required)
J.D.O. Neonate Intensive Care Unit
May 19,2010 – 12:40 AM 148083 Mrs. Ediza P. Sabang Mrs. Armida B. Gutierrez

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1C
CORD CARE FORM
Republic of the Philippines

Professional Regulation Commission

Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in LAPU-LAPU DISTRICT HOSPITAL/LAPU-LAPU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province
Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only Immediate Newborn Cord Nurse on Duty SUPERVISED BY
Time Started Case Number Care PERFORMED (Name AND Signature) Clinical Instructor
(not applicable for Birthing Indicate where performed e.g. D.R., (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) Nursery, NICU, or Home required)
A.D.M. Delivery Room
July 12,2010 – 8:30 PM 40682 Mrs. Ma. Lilane D. Berdin Mrs. Edna E. Reroma

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1C
CORD CARE FORM
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only Immediate Newborn Cord Nurse on Duty SUPERVISED BY
Time Started Case Number Care PERFORMED (Name AND Signature) Clinical Instructor
(not applicable for Birthing Indicate where performed e.g. D.R., (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) Nursery, NICU, or Home required)
C.N.A. Delivery Room
October 12,2010 – 11:57 AM 1010200 Mrs. Teresita Y. Sayson Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)
 ODC Form 1C
CORD CARE FORM
Republic of the Philippines
Professional Regulation Commission
Board of Nursing

UNIVERSITY OF THE VISAYAS

College of Nursing
Gov. M. Cuenco Ave., Banilad, Mandaue City, 6014, Philippines
TeleFax No. (032) 416-1538, 346-9292 loc. 622
Autonomous Status: July 15, 2010 until July 14, 2013; Deregulated Status: May 27, 2010 until May 26, 2013

IMMEDIATE NEWBORN CORD CARE in MINGLANILLA DISTRICT HOSPITAL/MINGLANILLA/CEBU CITY

Hospital/ Home/Lying-in clinical, Municipality/City/Province

Prepared by:
Printed Nam e and Signature of Student: CARLA MAE G. YUBAL

Date Performed and Patient’s INITIAL only Immediate Newborn Cord Nurse on Duty SUPERVISED BY
Time Started Case Number Care PERFORMED (Name AND Signature) Clinical Instructor
(not applicable for Birthing Indicate where performed e.g. D.R., (If Midwife on duty, Signature not Name and Signature
Homes/Lying-in clinics/Homes) Nursery, NICU, or Home required)
J.M.O. Delivery Room
October 12,2010 – 4:27 PM 10-10014 Mrs. Mary M. Aberia Mrs. Annabelle A. Catalan

Noted by: MRS. YVONNE Y. PEÑAN Approved by: MR. RESTY L. PICARDO
Clinical Coordinator, PRC I.D. No.: 0130427 Valid Until: November 2, 2012 Dean, PRC I.D. No.: 0280889 Valid Until: December 27, 2013
Date Document Signed: ________________ Time: ____________________ Date Document Signed: ________________ Time: ____________________
Please specify Highest Degree Earned: RN, MAN Please specify Highest Degree Earned: LLB, RN, MAN

(STRICTLY NO DESIGNATES)