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This document contains forms from Ateneo de Davao University for nursing students to record their surgical scrub and circulating nurse experiences in hospitals. The forms include spaces for the student's name and signature, date, patient's initials, surgical procedure performed, supervising OR nurse and clinical instructor's names and signatures. The forms must be noted and approved by the clinical coordinator and dean of the university nursing program.

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47 views3 pages

Or Exhibit Form

This document contains forms from Ateneo de Davao University for nursing students to record their surgical scrub and circulating nurse experiences in hospitals. The forms include spaces for the student's name and signature, date, patient's initials, surgical procedure performed, supervising OR nurse and clinical instructor's names and signatures. The forms must be noted and approved by the clinical coordinator and dean of the university nursing program.

Uploaded by

Aewooncardivilla21
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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Ateneo de Davao University ODC Form 2A

E. Jacinto St., Davao City O.R. SCRUB FORM


(082) 221-2411 / www.addu.edu.ph Major
Granted Autonomy by CHED, Year 2002

SURGICAL SCRUB in _____________________________________________________________________________


Hospital, Municipality/ City/ Province
Prepared by:
Printed Name with Signature of Student ___________________________________________________________

Date Pa�ent’s INITIALS (only) SUPERVISED BY


Performed SURGICAL PROCEDURE O.R Nurse on Duty Clinical Instructor
and 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 Un�l____________ Dean, PRC I.D. No. ______________________ Valid Un�l ______________
Date document is signed: ______________________ Time________________ Date document is signed: _________________ Time__________________
Please specify Highest Nursing Degree Earned:__________________________ Please specify Highest Nursing Degree Earned:______________________

(STRICTLY NO DESIGNATES)
Ateneo de Davao University ODC Form 2A
E. Jacinto St., Davao City O.R. SCRUB FORM
(082) 221-2411 / www.addu.edu.ph Minor
Granted Autonomy by CHED, Year 2002

SURGICAL SCRUB in _____________________________________________________________________________


Hospital, Municipality/ City/ Province
Prepared by:
Printed Name with Signature of Student ___________________________________________________________

Date Pa�ent’s INITIALS (only) SUPERVISED BY


Performed SURGICAL PROCEDURE O.R Nurse on Duty Clinical Instructor
and 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 Un�l____________ Dean, PRC I.D. No. ______________________ Valid Un�l ______________
Date document is signed: ______________________ Time________________ Date document is signed: _________________ Time__________________
Please specify Highest Nursing Degree Earned:__________________________ Please specify Highest Nursing Degree Earned:______________________

(STRICTLY NO DESIGNATES)
Ateneo de Davao University ODC Form 2B
E. Jacinto St., Davao City CIRCULATING NURSE
(082) 221-2411 / www.addu.edu.ph
Granted Autonomy by CHED, Year 2002

CIRCULATING NURSE in _____________________________________________________________________________


Hospital, Municipality/ City/ Province
Prepared by:
Printed Name with Signature of Student ___________________________________________________________

Date Pa�ent’s INITIALS (only) SUPERVISED BY


Performed SURGICAL PROCEDURE O.R Nurse on Duty Clinical Instructor
and 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 Un�l____________ Dean, PRC I.D. No. ______________________ Valid Un�l ______________
Date document is signed: ______________________ Time________________ Date document is signed: _________________ Time__________________
Please specify Highest Nursing Degree Earned:__________________________ Please specify Highest Nursing Degree Earned:______________________

(STRICTLY NO DESIGNATES)

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