This document contains a surgical scrub form for a nursing student from Manila Adventist Medical Center and Colleges. It lists 4 procedures the student assisted with from February 12 to 27, 2012, including a laparoscopic cholecystectomy, herniorophy, TAHBSO, and thyroidectomy. Each entry includes the patient's initials, date and time, procedure name, supervising nurse and instructor. Clinical coordinators, the chief nurse and dean were required to note and approve the documented scrubs.
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This document contains a surgical scrub form for a nursing student from Manila Adventist Medical Center and Colleges. It lists 4 procedures the student assisted with from February 12 to 27, 2012, including a laparoscopic cholecystectomy, herniorophy, TAHBSO, and thyroidectomy. Each entry includes the patient's initials, date and time, procedure name, supervising nurse and instructor. Clinical coordinators, the chief nurse and dean were required to note and approve the documented scrubs.
This document contains a surgical scrub form for a nursing student from Manila Adventist Medical Center and Colleges. It lists 4 procedures the student assisted with from February 12 to 27, 2012, including a laparoscopic cholecystectomy, herniorophy, TAHBSO, and thyroidectomy. Each entry includes the patient's initials, date and time, procedure name, supervising nurse and instructor. Clinical coordinators, the chief nurse and dean were required to note and approve the documented scrubs.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
This document contains a surgical scrub form for a nursing student from Manila Adventist Medical Center and Colleges. It lists 4 procedures the student assisted with from February 12 to 27, 2012, including a laparoscopic cholecystectomy, herniorophy, TAHBSO, and thyroidectomy. Each entry includes the patient's initials, date and time, procedure name, supervising nurse and instructor. Clinical coordinators, the chief nurse and dean were required to note and approve the documented scrubs.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
Download as doc, pdf, or txt
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ODC Form 1
O.R. SCRUB FORM Major MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. 1975 DONADA ST., PASAY CITY METRO MANILA 1300 TEL. NO. 525-91-91 LOC 282, FAX: (632) 5243256, email ad: mac_registrars office @yahoo.com SURGICAL SCRUB in MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. NCR Hospital, Municipality/City/Province Prepared by: Name of Student: TARALA, GAY DEBONAIRE B. Student_____________________________
Signature of
Date Performed and
Time Started
Patients Initial/ Case Number
PROCEDURE PERFORMED
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
February 12, 2012
10:05 am
De Borja, B./ 079421
Laparoscopyic Cholecystectomy
Aleli Sarah Del Rio
Omer Rey T. Daquila
Noted by:
Concurred by:
Clinical Coordinator, (Print Name and Signature)___________________
PRC I.D. No._____________________ Valid PNA No._______________________ Valid Date document is signed:___________________ Please specify Highest Nursing Degree
Approved by: Dean, (Print Name and Signature)___________________
ODC Form 1 O.R. SCRUB FORM Major PRC I.D. No._____________________ Valid Until___________________ PNA No._______________________ Valid Until____________________ ADPCN No._____________________ Valid Until____________________ Date document is signed:___________________ Time:______________ Please specify Highest Nursing Degree Earned:_____________________ MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. 1975 DONADA ST., PASAY CITY METRO MANILA 1300 TEL. NO. 525-91-91 LOC 282, FAX: (632) 5243256, email ad: mac_registrars office @yahoo.com SURGICAL SCRUB in MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. NCR Hospital, Municipality/City/Province Prepared by: Name of Student: TARALA, GAY DEBONAIRE B. Student_____________________________
Signature of
Date Performed and
Time Started
Patients Initial/ Case Number
PROCEDURE PERFORMED
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
February 26, 2012
5:43 pm
Marilyn Flavier Estysen/
12021-15-79
Herniorophy (left) lomentectomy
Marivi M. Pineda
Ricky G. Romulu
Noted by:
Concurred by:
Clinical Coordinator, (Print Name and Signature)___________________
Signature)__________________________ PRC I.D. No._____________________ Valid Until___________________ Until___________________ PNA No._______________________ Valid Until____________________ Until____________________ Date document is signed:___________________ Time:______________ Time:______________
Chief Nurse: Print Name and
PRC I.D. No._____________________ Valid PNA No._______________________ Valid Date document is signed:___________________
ODC Form 1 O.R. SCRUB FORM Major Please specify Highest Nursing Degree
Approved by: Dean, (Print Name and Signature)___________________
PRC I.D. No._____________________ Valid Until___________________ PNA No._______________________ Valid Until____________________ ADPCN No._____________________ Valid Until____________________ Date document is signed:___________________ Time:______________ Please specify Highest Nursing Degree Earned:_____________________ MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. 1975 DONADA ST., PASAY CITY METRO MANILA 1300 TEL. NO. 525-91-91 LOC 282, FAX: (632) 5243256, email ad: mac_registrars office @yahoo.com SURGICAL SCRUB in MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. NCR Hospital, Municipality/City/Province Prepared by: Name of Student: TARALA, GAY DEBONAIRE B. Student_____________________________
Signature of
Date Performed and
Time Started
Patients Initial/ Case Number
PROCEDURE PERFORMED
February 26, 2012
3:37 pm
Cecilia Tayle Atienza/
12021-1591
TAHBSO
Noted by:
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
Marivi M. Pineda
Ricky G. Romulu
Concurred by:
Clinical Coordinator, (Print Name and Signature)___________________
Signature)__________________________
Chief Nurse: Print Name and
ODC Form 1 O.R. SCRUB FORM Major PRC I.D. No._____________________ Valid Until___________________ Until___________________ PNA No._______________________ Valid Until____________________ Until____________________ Date document is signed:___________________ Time:______________ Time:______________ Please specify Highest Nursing Degree Earned:_____________________ Earned:_____________________
PRC I.D. No._____________________ Valid
PNA No._______________________ Valid Date document is signed:___________________ Please specify Highest Nursing Degree
Approved by: Dean, (Print Name and Signature)___________________
PRC I.D. No._____________________ Valid Until___________________ PNA No._______________________ Valid Until____________________ ADPCN No._____________________ Valid Until____________________ Date document is signed:___________________ Time:______________ Please specify Highest Nursing Degree Earned:_____________________ MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. 1975 DONADA ST., PASAY CITY METRO MANILA 1300 TEL. NO. 525-91-91 LOC 282, FAX: (632) 5243256, email ad: mac_registrars office @yahoo.com SURGICAL SCRUB in MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. NCR Hospital, Municipality/City/Province Prepared by: Name of Student: TARALA, GAY DEBONAIRE B. Student_____________________________
Signature of
Date Performed and
Time Started
Patients Initial/ Case Number
PROCEDURE PERFORMED
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
February 26, 2012
11:05 pm
Hermine Medrano Abajero/ 12021-547
Thyroidectomy (right) thyroider lobectomy
Marivi M. Pineda
Ricky G. Romulu
ODC Form 1 O.R. SCRUB FORM Major Noted by:
Concurred by:
Clinical Coordinator, (Print Name and Signature)___________________
PRC I.D. No._____________________ Valid PNA No._______________________ Valid Date document is signed:___________________ Please specify Highest Nursing Degree
Approved by: Dean, (Print Name and Signature)___________________
PRC I.D. No._____________________ Valid Until___________________ PNA No._______________________ Valid Until____________________ ADPCN No._____________________ Valid Until____________________ Date document is signed:___________________ Time:______________ Please specify Highest Nursing Degree Earned:_____________________ MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. 1975 DONADA ST., PASAY CITY METRO MANILA 1300 TEL. NO. 525-91-91 LOC 282, FAX: (632) 5243256, email ad: mac_registrars office @yahoo.com SURGICAL SCRUB in MANILA ADVENTIST MEDICAL CENTER AND COLLEGES, INC. NCR Hospital, Municipality/City/Province Prepared by: Name of Student: TARALA, GAY DEBONAIRE B. Student_____________________________
Signature of
ODC Form 1 O.R. SCRUB FORM Major Date Performed and Time Started
Patients Initial/ Case Number
PROCEDURE PERFORMED
February 27, 2012
10:02 am
Rosana Hernandez Rivera/ 1202-1645
TAHBSO
Noted by:
O.R. Nurse on Duty
(Name and Signature)
SUPERVISED BY Clinical Instructor Name and Signature
Marivi M. Pineda
Ricky G. Romulu
Concurred by:
Clinical Coordinator, (Print Name and Signature)___________________
