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    5555 Form Cases-New Form

    Uploaded by

    Jaja Ramos
    This document contains 4 forms used by the University of Perpetual Help System - GMA Campus for documenting procedures performed by nursing students. The forms are for documenting a surgical scrub, actual delivery, assisted delivery, and immediate newborn cord care. Each form collects information such as the date, time, patient name, procedure performed, supervising staff, and requires signatures from the student, clinical instructor, clinical coordinator, and dean to verify the procedure was properly completed and supervised.

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    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    5555 Form Cases-New Form

    Uploaded by

    Jaja Ramos
    33 views4 pages
    This document contains 4 forms used by the University of Perpetual Help System - GMA Campus for documenting procedures performed by nursing students. The forms are for documenting a surgical scrub, actual delivery, assisted delivery, and immediate newborn cord care. Each form collects information such as the date, time, patient name, procedure performed, supervising staff, and requires signatures from the student, clinical instructor, clinical coordinator, and dean to verify the procedure was properly completed and supervised.

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    This document contains 4 forms used by the University of Perpetual Help System - GMA Campus for documenting procedures performed by nursing students. The forms are for documenting a surgical scrub, actual delivery, assisted delivery, and immediate newborn cord care. Each form collects information such as the date, time, patient name, procedure performed, supervising staff, and requires signatures from the student, clinical instructor, clinical coordinator, and dean to verify the procedure was properly completed and supervised.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    33 views4 pages

    5555 Form Cases-New Form

    Uploaded by

    Jaja Ramos
    This document contains 4 forms used by the University of Perpetual Help System - GMA Campus for documenting procedures performed by nursing students. The forms are for documenting a surgical scrub, actual delivery, assisted delivery, and immediate newborn cord care. Each form collects information such as the date, time, patient name, procedure performed, supervising staff, and requires signatures from the student, clinical instructor, clinical coordinator, and dean to verify the procedure was properly completed and supervised.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 4

    ODC Form 1 O.R.

    SCRUB FORM

    UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS


    BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
    PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: [email protected], Website: uphsl.edu.ph

    SURGICAL SCRUB in __________________________________________________________________ Hospital, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

    Date Performed and Time Started

    Patients Name Case Number

    PROCEDURE PERFORMED

    O.R. Nurse On Duty (Name only)

    SUPERVISED BY Clinical Instructor Name and Signature

    Noted by: Chief Nurse


    PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

    Concurred by:

    ____ Clinical Coordinator

    ____

    PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

    Dean 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:_______________________________________________________________________________

    ODC Form 2 ACTUAL DELIVERY

    UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS


    BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
    PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: [email protected], Website: uphsl.edu.ph

    ACTUAL DELIVERY in __________________________________________________________________ Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

    Date Performed and Time Started

    Patients Name Case Number


    (Not applicable for Birthing/Lying-In Clinics/Homes)

    PROCEDURE PERFORMED

    O.R. Nurse / Midwife On Duty (Name only)

    SUPERVISED BY Clinical Instructor Name and Signature

    Noted by: Chief Nurse


    PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

    Concurred by:

    ____ Clinical Coordinator

    ____

    PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

    Dean 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:_______________________________________________________________________________

    For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN

    ODC Form 3 D.R. ASSIST FORM

    UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS


    BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
    PHONE #: (02)490-7748, Fax #: (046)890-1393, Email Add: [email protected], Website: uphsl.edu.ph

    ASSISTED DELIVERY in __________________________________________________________________ Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

    Date Performed and Time Started

    Patients Name Case Number


    (Not applicable for Birthing/Lying-In Clinics/Homes)

    PROCEDURE PERFORMED

    D.R. Nurse / Midwife On Duty (Name only)

    SUPERVISED BY Clinical Instructor Name and Signature

    Noted by: Chief Nurse


    PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

    Concurred by:

    ____ Clinical Coordinator

    ____

    PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

    Dean 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:_______________________________________________________________________________

    For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN

    UNIVERSITY OF PERPETUAL HELP SYSTEM-GMA CAMPUS


    BGRY. SAN GABRIEL, GEN. MARIANO ALVAREZ, CAVITE
    PHONE #:(02)490-7748, Fax #: (046)890-1393, Email Add: [email protected], Website: uphsl.edu.ph

    ODC Form 4 D.R. IMMEDIATE NEWBORN

    IMMEDIATE NEWBORN CORD CARE in __________________________________________________________________ Hospital/Home/Lying-In-Clinic, Municipal/City/Province Prepared by: Name of Student ________________________________________ Signature of Student ____________________________________

    Date Performed and Time Started

    Patients Name Case Number


    (Not applicable for Birthing/Lying-In Clinics/Homes)

    Immediate Newborn Cord Care Performed


    Indicate where performed e.g. D.R., Nursery, NICU, or Home

    D.R. Nurse / Midwife On Duty (Name only)

    SUPERVISED BY Clinical Instructor Name and Signature

    Noted by: Chief Nurse


    PRC I.D. No. Valid Until PNA No. Valid Until Date document is signed: Time Date Please specify Highest Nursing Degree Earned: Approved by:

    Concurred by:

    ____ Clinical Coordinator

    ____

    PRC I.D No. Valid Until ___________________ PNA No. Valid Until ___________________ Date document is signed: Time_______________ Please specify Highest Nursing Degree Earned:

    Dean 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:_______________________________________________________________________________

    For deliveries performed in Lying-In and Homes, ONLY THE CLINICAL INSTRUCTOR AND CLINICAL COORDINATOR are REQUIRED TO SIGN

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