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    New PRC Form Sample

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    Lanie Esteban Espejo
    This document contains records of surgical scrubs and actual delivery procedures performed by Jessica Marie Del Rosario Bartolome as a student nurse. It includes details of 11 surgical scrub procedures conducted at various hospitals from 2009 to 2012 and 3 actual delivery procedures observed at Calumpit District Hospital in May 2011. The document provides information on the procedures, dates, times, patients and supervising clinical instructors for each experience.

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    New PRC Form Sample

    Uploaded by

    Lanie Esteban Espejo
    362 views8 pages
    This document contains records of surgical scrubs and actual delivery procedures performed by Jessica Marie Del Rosario Bartolome as a student nurse. It includes details of 11 surgical scrub procedures conducted at various hospitals from 2009 to 2012 and 3 actual delivery procedures observed at Calumpit District Hospital in May 2011. The document provides information on the procedures, dates, times, patients and supervising clinical instructors for each experience.

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    This document contains records of surgical scrubs and actual delivery procedures performed by Jessica Marie Del Rosario Bartolome as a student nurse. It includes details of 11 surgical scrub procedures conducted at various hospitals from 2009 to 2012 and 3 actual delivery procedures observed at Calumpit District Hospital in May 2011. The document provides information on the procedures, dates, times, patients and supervising clinical instructors for each experience.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    362 views8 pages

    New PRC Form Sample

    Uploaded by

    Lanie Esteban Espejo
    This document contains records of surgical scrubs and actual delivery procedures performed by Jessica Marie Del Rosario Bartolome as a student nurse. It includes details of 11 surgical scrub procedures conducted at various hospitals from 2009 to 2012 and 3 actual delivery procedures observed at Calumpit District Hospital in May 2011. The document provides information on the procedures, dates, times, patients and supervising clinical instructors for each experience.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 8

    BulacanStateUniversity COLLEGE OF NURSING

    Guinhawa, City of Malolos, Bulacan (044) 791-94-00 [email protected]


    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 DateWhenSchool was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    SURGICAL SCRUB in JOSE B. LINGAD MEMORIAL REGIONAL HOSPITAL Dolores, City of San Fernando, Pampanga Date Performed and Time Started May 10, 2011 11:57 AM-12:28 PM Patients INITIALS (only) CASE NUMBER CBC, 275762
    Clinical Coordinator

    O.R. FORM 1A
    MAJOR O.R. SCRUB FORM Supervised by Clinical Instructor (Name and Signature) Alvin A. Isip, RN, MAN

    SURGICAL PROCEDURE PERFORMED Indirect Inguinal Hernia Left Reducible

    O.R. Nurse On Duty ( Name and Signature) Mercado, Marites T., RN

    Student

    CTC Number: CCI201121302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd


    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    Bulacan State University COLLEGE OF NURSING


    Guinhawa, City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 DateWhenSchool was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    SURGICAL SCRUB in MARY IMMACULATE MATERNITY HOSPITAL Sto. Rosario, City of Malolos, Bulacan Date Performed and Time Started January 2, 2012 12:07- 1:20 PM January 5, 2012 7:30- 8:25 AM Patients INITIALS (only) CASE NUMBER MCR 12-002 ESC 12-005 SURGICAL PROCEDURE PERFORMED Exploratory Laparotomy, Left Salpingectomy Low Transverse Caesarian Section 1
    Clinical Coordinator

    O.R. FORM 1A
    MAJOR O.R. SCRUB FORM O.R. Nurse On Duty ( Name and Signature) Supervised by Clinical Instructor (Name and Signature) Elvira B. Vitug, RN Elvira B. Vitug, RN

    Alvin G. Crisostomo, RN DJ Jhoanna F.de Jesus, RN

    Student

    CTC Number:CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd


    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    BulacanStateUniversity COLLEGE OF NURSING


    Guinhawa, City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 DateWhenSchool was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    SURGICAL SCRUB in JOSE B. LINGAD MEMORIAL REGIONAL HOSPITAL Dolores, City of San Fernando, Pampanga Date Performed and Time Started May 9, 2011 9: 30 AM-11:25 AM May 16, 2011 12:33 PM- 1:10 PM Patients INITIALS (only) CASE NUMBER MLS, 313951 RVI, 315403 SURGICAL PROCEDURE PERFORMED Right Total, Left Subtotal Thyroidectomy Emergency Caesarian Section, Live Baby Boy + Bilateral Tubal Ligation
    Clinical Coordinator

    O.R.FORM 1B
    MAJOR O.R. CIRCULATING FORM Supervised by Clinical Instructor (Name and Signature) Alvin A. Isip, RN, MAN Alvin A. Isip, RN, MAN

    O.R. Nurse On Duty ( Name and Signature) Edrey S. Vergara , RN Roger D. Amio, RN

    Student

    CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd


    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    BulacanStateUniversity COLLEGE OF NURSING


    Guinhawa, City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    SURGICAL SCRUB in MARY IMMACULATE MATERNITY HOSPITAL O.R. FORM 1B Sto. Rosario, City of Malolos, Bulacan MAJOR O.R. CIRCULATING FORM Date Performed and Time Started January 3, 2012 2:32-3:48 PM Patients INITIALS (only) CASE NUMBER CPT 12-005
    Clinical Coordinator

    SURGICAL PROCEDURE PERFORMED Cholecystectomy

    O.R. Nurse On Duty ( Name and Signature) Alvin G. Crisostomo, RN

    Supervised by Clinical Instructor (Name and Signature) Elvira B. Vitug, RN

    Student

    CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd

    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    BulacanStateUniversity COLLEGE OF NURSING


    Guinhawa,City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    SURGICAL SCRUB in MARY IMMACULATE MATERNITY HOSPITAL Sto. Rosario, City of Malolos, Bulacan Date Performed and Time Started January 8, 20112 1:45 PM Patients INITIALS (only) CASE NUMBER MPM 12-009
    Clinical Coordinator

    O.R. FORM 1C
    MINOR FORM Supervised by Clinical Instructor (Name and Signature) Elvira B. Vitug, RN

    SURGICAL PROCEDURE PERFORMED Dilatation and Curettage

    O.R. Nurse On Duty ( Name and Signature) Concordia M. Hernandez, RN

    Student

    CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd


    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    Bulacan State University COLLEGE OF NURSING


    Guinhawa, City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: BulacanStateUniversity Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    SURGICAL SCRUB in JOSE B. LINGAD REGIONAL MEMORIAL HOSPITAL Dolores, City of San Fernando, Pampanga Date Performed and Time Started September 18, 2009 8:30 AM April 28, 2011 9:15 AM Patients INITIALS (only) CASE NUMBER RC 251695 LL 314252
    Clinical Coordinator

    O.R. FORM 1C
    MINOR FORM Supervised by Clinical Instructor (Name and Signature) Maria Joida R. Ocampo RN, MSN Alvin A. Isip, RN, MAN

    SURGICAL PROCEDURE PERFORMED Episiorrhaphy Central Venous Pressure Insertion

    O.R. Nurse On Duty ( Name and Signature) Ma. Riza M. Tecson RN Edrey S. Vergara , RN

    Student

    CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Bulacan State University

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd

    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    COLLEGE OF NURSING
    Guinhawa,City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: 2008 Year Graduated from the BSN Program: 2012

    Date Performed and Time of Delivery May 24,2011 9:40 am May 27,2011 1:20 pm May 30,2011 4:50 am

    ACTUAL DELIVERY SCRUB in CALUMPIT DISTRICT HOSPITAL D.R. FORM 1D Caniogan, Calumpit, Bulacan ACTUAL DELIVERY FORM Patients INITIALS (only) Supervised by PROCEDURE D.R. Nurse On Duty Clinical Instructor CASE NUMBER PERFORMED ( Name and Signature) (Name and Signature) LND, 167720 AD, 138511 MEP, 164928
    Clinical Coordinator

    Normal Spontaneous Delivery Normal Spontaneous Delivery Normal Spontaneous Delivery

    Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN

    Daisy Reyes, RN Daisy Reyes, RN Daisy Reyes, RN

    Student

    CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JESSICA MARIE D.R. BARTOLOME

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd


    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

    Bulacan State University

    COLLEGE OF NURSING
    Guinhawa, City of Malolos, Bulacan (044) 791-94-00 [email protected]
    NAME OF STUDENT: BARTOLOME, JESSICA MARIE DEL ROSARIO Name of School: Bulacan State University Address of School:Guinhawa, City of Malolos, Bulacan Recognition and Accreditation Level: December 1, 2011, Level 1 Date When School was Recognized: December 4, 2003 Board Resolution First Course: NA School Graduated: NA Year of Admission in the BSN Program: June 2008 Year Graduated from the BSN Program: April 2012

    IMMEDIATE NEWBORN CORD CARE in CALUMPIT DISTRICT HOSPITAL Caniogan, Calumpit, Bulacan Patients INITIALS (only) Date Performed and Immediate Newborn Cord Care Time of Delivery May 21, 2011 8:05 PM May 23, 2011 9:45 AM May 27, 2011 6:15 AM CASE NUMBER B.B.M 165174 B.B.P 166105 B.B.T 166034
    Clinical Coordinator

    ICNB FORM 1E
    IMMEDIATE CARE OF THE NEWBORN FORM

    Area Performed Delivery Room Delivery Room Delivery Room

    D.R. Nurse On Duty ( Name and Signature) Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN Jennifer P. Teodoro, RN

    Supervised by Clinical Instructor (Name and Signature) Daisy S. Reyes, RN Daisy S. Reyes, RN Daisy S. Reyes, RN

    JESSICA MARIE D.R. BARTOLOME Student


    CTC Number: CCI2011 21302322 Date : March 20,2012 Place: City of Malolos, Bulacan

    Degree: BSN, MSN Date Signed:_____________ PRC No: 0241987 Valid Until: March 24, 2015 PNA No:053382 Valid Until: December 31, 2012

    Dean

    JENNIFER S. CENTENO, RN, MSN

    LOIDA O. CRESPO, RN, MSN, MAEd


    Degree: BSN, MSN, MAEd Date Signed:_____________ PRC No:0094388Valid Until:December 5, 2013 PNA No: 18308Valid Until: Lifetime ADPCN No: 11-167 Valid Until: December 2012

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