This document contains forms for students to document their surgical scrub and circulating experiences at De La Salle University Medical Center. The forms require the student's name, date and time of the procedure, patient initials, case number, surgical procedure performed, supervising nurse and instructor. The forms must be signed by the student, approved by the level 3 coordinator and dean with their nursing credentials.
This document contains forms for students to document their surgical scrub and circulating experiences at De La Salle University Medical Center. The forms require the student's name, date and time of the procedure, patient initials, case number, surgical procedure performed, supervising nurse and instructor. The forms must be signed by the student, approved by the level 3 coordinator and dean with their nursing credentials.
This document contains forms for students to document their surgical scrub and circulating experiences at De La Salle University Medical Center. The forms require the student's name, date and time of the procedure, patient initials, case number, surgical procedure performed, supervising nurse and instructor. The forms must be signed by the student, approved by the level 3 coordinator and dean with their nursing credentials.
This document contains forms for students to document their surgical scrub and circulating experiences at De La Salle University Medical Center. The forms require the student's name, date and time of the procedure, patient initials, case number, surgical procedure performed, supervising nurse and instructor. The forms must be signed by the student, approved by the level 3 coordinator and dean with their nursing credentials.
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DE LA SALLE HEALTH SCIENCES INSTITUTE ODC Form 2A
City of Dasmariñas, Cavite 4114, Philippines O.R. SCRUB FORM
(Cavite Line) 481-8000 (Manila Line) 988-3100, Fax (046) 481-8011 Major www.dlshsi.edu.ph PAASCU Accredited – Level 3 November 2014 – November 2019
SURGICAL SCRUB IN DE LA SALLE UNIVERSITY MEDICAL CENTER, CITY of DASMARIÑAS, CAVITE
Hospital, Municipality/City/Province
Prepared by: Printed Name with Signature of Student
Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY
and (Name AND Signature) Clinical Instructor Time Started Case Number SURGICAL PROCEDURE Name and Signature
PERFORMED
Noted by: LEON L. FOJAS, RN, MAN Approved by: _________________________________________
(Printed Name and Signature) (Printed Name and Signature) Level 3 Coordinator, PRC I.D No.___________ Valid Until _____________ Dean, PRC I.D No. ____________ Valid Until _____________ Date document is signed: Time Date document is signed: Time Please specify Highest Nursing Degree Earned: ________ Specify Highest Nursing Degree Earned: ____ DE LA SALLE HEALTH SCIENCES INSTITUTE ODC Form 2B City of Dasmariñas, Cavite 4114, Philippines O.R. CIRCULATING (Cavite Line) 481-8000 (Manila Line) 988-3100, Fax (046) 481-8011 FORM www.dlshsi.edu.ph Major PAASCU Accredited – Level 3 November 2014 – November 2019
CIRCULATING IN DE LA SALLE UNIVERSITY MEDICAL CENTER, CITY of DASMARIÑAS, CAVITE
Hospital, Municipality/City/Province
Prepared by: Printed Name with Signature of Student
Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY
and (Name AND Signature) Clinical Instructor Time Started Case Number SURGICAL PROCEDURE Name and Signature
(Printed Name and Signature) (Printed Name and Signature) Level 3 Coordinator, PRC I.D No.__________ Valid Until ____________ Dean, PRC I.D No. ____________ Valid Until _____________ Date document is signed: Time Date document is signed: Time Please specify Highest Nursing Degree Earned: _____ Specify Highest Nursing Degree Earned: _______________
