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    Midwives Cases

    Uploaded by

    Melanie Pongan

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Midwives Cases

    Uploaded by

    Melanie Pongan
    7 views4 pages

    Original Title

    midwives_cases

    Copyright

    © © All Rights Reserved

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    PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    7 views4 pages

    Midwives Cases

    Uploaded by

    Melanie Pongan

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    PRC FORM No.

    106
    Republic of the Philippines
    (Revised October 2010)
    Professional Regulation Commission
    Lucena City

    BOARD OF MIDWIFERY
    Record of Actual Deliveries Handled

    Please Check:

    ✔ Graduate Midwife Registered Nurse

    Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

    Date & CHECK SUPERVISED BY:


    Case Complete diagnosis Full name, address of
    NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
    No. (gravida_para_) facility & contact number Signature
    Performed DELIVERY & contact No. Designation Expiration date

    1. Melan

    2.

    3.

    4.

    5.

    6.

    7.

    8.

    9.

    10.
    Date & CHECK SUPERVISED BY:
    Case Complete diagnosis Full name, address of
    NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
    No. (gravida_para_) facility & contact number Signature
    Performed DELIVERY & contact No. Designation Expiration date

    11.

    12.

    13.

    14.

    15.

    16.

    17.

    18.

    19.

    20.

    NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.
    2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. 7392.

    SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. Affiant


    exhibiting to me his/her Residence Certificate No. ____________ issued at _______________________ on ____________________.
    CERTIFIED CORRECT:

    Signature: ___________________ Date: ___________


    Affix Printed Name: ________________________________
    ________________________________ Documentary Stamp Designation:__________________________________
    (to be posted on the last page)
    Administering Officer or Notary Public Lic. No.:_____________ Expiry Date:______________
    PRC FORM No. 107
    Republic of the Philippines
    (Revised October 2010)
    Professional Regulation Commission
    Lucena City

    BOARD OF MIDWIFERY
    Record of Actual Repair of Perineal Lacerations

    Please Check:

    ✔ Graduate Midwife Registered Nurse

    Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

    Date & CHECK SUPERVISED BY:


    Case Complete diagnosis Full name, address of
    NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
    No. (gravida_para_) facility & contact number Signature
    Performed DELIVERY & contact No. Designation Expiration date

    1.

    2.

    3.

    4.

    5.

    (See back page)


    PRC FORM No. 107-A
    Republic of the Philippines
    (Revised October 2010)
    Professional Regulation Commission
    Lucena City

    BOARD OF MIDWIFERY
    Record of Actual Intravenous Insertions

    Name of Applicant: _______________________________________________________________ School: _______________________________________________________________________

    Date & CHECK SUPERVISED BY:


    Case Complete diagnosis Full name, address of
    NAME and address OF PATIENT Time IF HOME PRINTed name Position/ License No./
    No. (gravida_para_) facility & contact number Signature
    Performed DELIVERY & contact No. Designation Expiration date

    1.

    2.

    3.

    4.

    5.

    NOTE: 1) For graduate midwives: Supervision must be by qualified faculty / clinical instructor.
    2) for Registered Midwives who supervise students must present certificate of training on the Expanded Functions as provided for under R.A. 7392.

    SUBSCRIBED AND SWORN TO before me this __________________________________ at ________________________. Affiant


    exhibiting to me his/her Residence Certificate No. ____________ issued at _______________________ on ____________________.
    CERTIFIED CORRECT:

    Signature: ___________________ Date: ___________


    Affix Printed Name: ________________________________
    ________________________________ Documentary Stamp Designation:__________________________________
    (to be posted on the last page)
    Administering Officer or Notary Public Lic. No.:_____________ Expiry Date:______________

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