COLLEGE OF ST.

JOHN – ROXAS ODC Form 1A

ACTUAL DELIVERY
Member: Association of LASSSAI Accredited SuperSchools (ALAS) FORM
Gov. Atila Balgos Ave., Banica, Roxas City
5800 Capiz, Philippines

ACTUAL DELIVERY in ______ Roxas Memorial Provincial Hospital _____________

Hospital/Home/Lying-in Clinic, Municipality /City / Province
Prepared by:

Printed Name and Signature of Student: Francine U. Pajares______________

Date Patient’s INITIALS Only

D.R. Nurse On Duty SUPERVISED BY
Performed _____________________________________
Case Number PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
And (not applicable for Birthing/Lying-in
Time Started Clinics/Homes) Name Signature Name Signature

Francis Joe
11-24-23 Ms. KJS Normal Spontaneous Vaginal
Fuentes,
8:16 PM Delivery
RN, CCRN

Noted by: IRENE D. BELLOSILLO Approved by: MARIA RUBY F. FULLON ____
(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. __________ Valid Until _____________________ Dean, PRC I.D No. 0067603 Valid Until _________

Date document is signed: Time Date document is signed: Time

Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: ____ RN, MAN, PhD______

STRICTLY NO DESIGNATES

Office of the Chancellor: (036) 621 5688 loc.102∙ College of Nursing: (036) 621 5688 loc. 106. Registrar: (036) 522 4167 loc.104
 COLLEGE OF ST. JOHN – ROXAS ODC Form 1B
ASSISTED
Member: Association of LASSSAI Accredited SuperSchools (ALAS) DELIVERY FORM
Gov. Atila Balgos Ave.,Banica, RoxasCity
5800 Capiz, Philippines

INSTRUMENT SCRUB in ________Roxas Memorial Provincial Hospital______________________

Hospital/Home/Lying-in Clinic, Municipality /City / Province
Prepared by:
Printed Name and Signature of Student: _________Francine U. Pajares___________________________

Date Patient’s INITIALS Only PROCEDURE D.R. Nurse On Duty

Performed _____________________________________ (Name and Signature) SUPERVISED BY
PERFORMED
And Case Number (If Midwife on Duty, Signature Not Clinical Instructor
(not applicable for Birthing/Lying-in Required)
Time Started Clinics/Homes) Name Signature Name Signature

09-30-23 Imelda
Ms. EFG Cesarean Section
10: 30 AM Muyco, RN

Noted by: IRENE D. BELLOSILLO ____________ Approved by: MARIA RUBY F. FULLON ____
(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. _____ Valid Until_______________ Dean, PRC I.D No. 0067603 Valid Until _________________

Date document is signed: Time Date document is signed: Time

Please specify Highest Nursing Degree Earned: RN, MAN ______ Specify Highest Nursing Degree Earned: ____ RN, MAN, PhD______

STRICTLY NO DESIGNATES

Office of the Chancellor: (036) 621 5688 loc.102∙ College of Nursing: (036) 621 5688 loc. 106. Registrar: (036) 522 4167 loc.104
 COLLEGE OF ST. JOHN – ROXAS ODC Form 1C
CORD CARE FORM
Member: Association of LASSSAI Accredited SuperSchools (ALAS)
Gov. Atila Balgos Ave.,Banica, RoxasCity
5800 Capiz, Philippines

IMMEDIATE NEWBORN CORD CARE in ___________Roxas Memorial Provincial Hospital______________________

Hospital/Home/Lying-in Clinic, Municipality /City / Province
Prepared by:
Printed Name and Signature of Student: ______Francine U. Pajares_______________________________

Date Patient’s INITIALS Only D.R. Nurse On Duty

Immediate Newborn Cord SUPERVISED BY
Performed _____________________________________ (Name and Signature)
Case Number Care Performed (If Midwife on Duty, Signature Not Clinical Instructor
And (indicate where performed e.g. D. R.,
(not applicable for Birthing/Lying-in Required)
Nursery, NICU, or Home)
Time Started Clinics/Homes) Name Signature Name Signature

Duya, Baby Boy Francis Joe

10-27-23 Fuentes, RN,
NICU
6:58 PM CCRN

Noted by: IRENE D. BELLOSILLO __________________ Approved by: MARIA RUBY F. FULLON____
(Print Name and Signature (Print Name and Signature)

Clinical Coordinator, PRC I.D No. Valid Until ___________________ Dean, PRC I.D No. 0067603 Valid Until _____________

Date document is signed: Time Date document is signed: Time

Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: ____ RN, MAN, PhD______
STRICTLY NO DESIGNATES

Office of the Chancellor: (036) 621 5688 loc.102∙ College of Nursing: (036) 621 5688 loc. 106. Registrar: (036) 522 4167 loc.104
 COLLEGE OF ST. JOHN – ROXAS ODC Form 2A
O.R. SCRUB
Member: Association of LASSSAI Accredited SuperSchools (ALAS) MAJOR FORM
Gov. Atila Balgos Ave.,Banica, RoxasCity
5800 Capiz, Philippines

SURGICAL SCRUB in __________________Roxas Memorial Provincial Hospital_____________________________

Hospital, Municipality /City / Province
Prepared by:
Printed Name and Signature of Student: ___Rhea Grace M. Macabales_________________________________

Date Patient’s INITIALS Only D.R. Nurse On Duty

Performed _____________________________________ (Name and Signature) SUPERVISED BY
SURGICAL PROCEDURE
And Case Number (If Midwife on Duty, Signature Not Clinical Instructor
PERFORMED Required)
(not applicable for Birthing/Lying-in
Time Started Clinics/Homes) Name Signature Name Signature

Causing, Ferdinant Ma. Regina

01-22-2020 Open Reduction Cross
Arban David Paolo B. A. Palomo,
Pinning Radius, Application
Bauson, RN RN, MAN
1:45 PM of Cast Mold
0809

Noted by: MA. REGINA A. PALOMO Approved by: MARIA RUBY F. FULLON ____
(Print Name and Signature) (Print Name and Signature)

Clinical Coordinator, PRC I.D No. 0301838 Valid Until December 18, 2022 Dean, PRC I.D No. 0067603 Valid Until _________November 10, 2022_____

Date document is signed: Time Date document is signed: Time

Please specify Highest Nursing Degree Earned: RN, MAN Specify Highest Nursing Degree Earned: ____ RN, MAN, PhD______

STRICTLY NO DESIGNATES

Office of the Chancellor: (036) 621 5688 loc.102∙ College of Nursing: (036) 621 5688 loc. 106. Registrar: (036) 522 4167 loc.104
 COLLEGE OF ST. JOHN – ROXAS ODC Form 2B
O.R. CIRCULATING
Member: Association of LASSSAI Accredited SuperSchools (ALAS) FORM
Gov. Atila Balgos Ave.,Banica, RoxasCity
5800 Capiz, Philippines

CIRCULATING SCRUB in ___________________Roxas Memorial Provincial Hospital_____________________________

Hospital, Municipality /City / Province
Prepared by:
Printed Name and Signature of Student: _______Francine U. Pajares _____________________________________

Date Patient’s INITIALS Only D.R. Nurse On Duty

Performed _____________________________________ (Name and Signature) SUPERVISED BY
SURGICAL PROCEDURE
And Case Number (If Midwife on Duty, Signature Not Clinical Instructor
PERFORMED Required)
(not applicable for Birthing/Lying-in
Time Started Clinics/Homes) Name Signature Name Signature

Francis Joe
Fuentes, RN,
10-27-23
Ms. ABC Cesarean Section CCRN
11: 30 PM

Noted by: IRENE D. BELLOSILLO _________ Approved by: MARIA RUBY F. FULLON ____
(Print Name and Signature) (Print Name and Signature)
Clinical 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: RN, MAN Specify Highest Nursing Degree Earned: ____ RN, MAN, PhD______

STRICTLY NO DESIGNATES

Office of the Chancellor: (036) 621 5688 loc.102∙ College of Nursing: (036) 621 5688 loc. 106. Registrar: (036) 522 4167 loc.104
Office of the Chancellor: (036) 621 5688 loc.102∙ College of Nursing: (036) 621 5688 loc. 106. Registrar: (036)
522 4167 loc.104