UNIVERSITY OF SAN CARLOS

COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES ODC Form 1C
PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph CORD CARE FORM
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

IMMEDIATE NEWBORN CORD CARE in _____________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ____________________________________

Patient’s INITIALS (only) O.R. Nurse On Duty

Date Performed and Case Number IMMEDIATE NEWBORN CORD CARE PERFORMED (Name and Signature) SUPERVISED BY
Time Started (not applicable for Birthing Home/ (Indicate where performed e.g. D.R., Nursery, or Home) (If midwife on Duty, Signature Not Clinical Instructor
Lying-in Clinics/ Names) Required) (Name and Signature)

Noted by: __________________________________________________________ Approved by: _______________________________________________

(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_________________________________ Specify Highest Nursing Degree Earned_____________________________
 UNIVERSITY OF SAN CARLOS
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES ODC Form 1B
PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph ASSISTED DELIVERY FORM
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

ACTUAL DELIVERY in _____________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ____________________________________

Patient’s INITIALS (only) D.R. Nurse On Duty

Date Performed and Case Number PROCEDURE PERFORMED (Name and Signature) SUPERVISED BY
Time Started (not applicable for Birthing Home/ (If midwife on Duty, Signature Not Clinical Instructor
Lying-in Clinics/ Names) Required) (Name and Signature)
ASSISTED DELIVERY

Noted by: __________________________________________________________ Approved by: _______________________________________________

(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_________________________________ Specify Highest Nursing Degree Earned_____________________________
 UNIVERSITY OF SAN CARLOS
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph ODC Form 1A
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011 ACTUAL DELIVERY FORM

ACTUAL DELIVERY in _____________________________________________________

Hospital/Home/Lying-in Clinic, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ____________________________________

Patient’s INITIALS (only) D.R. Nurse On Duty

Date Performed and Case Number (Name and Signature) SUPERVISED BY
Time Started (not applicable for Birthing Home/ PROCEDURE PERFORMED (If midwife on Duty, Signature Not Clinical Instructor
Lying-in Clinics/ Names) Required) (Name and Signature)

Noted by: __________________________________________________________ Approved by: _______________________________________________

(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_________________________________ Specify Highest Nursing Degree Earned_____________________________
 UNIVERSITY OF SAN CARLOS
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES
PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph ODC Form 2B
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011 OR MINOR FORM

SURGICAL SCRUB in _____________________________________________________

Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ____________________________________

Date Performed and Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY
Time Started SURGICAL PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
Case Number (Name and Signature)

Noted by: __________________________________________________________ Approved by: _______________________________________________

(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_________________________________ Specify Highest Nursing Degree Earned_____________________________
 UNIVERSITY OF SAN CARLOS
COLLEGE OF NURSING, NASIPIT, TALAMBAN, CEBU CITY 6000 PHILIPPINES ODC Form 2A
PHONE: 032 3433005; FAX: 032 3433006; nursdean@usc.edu.ph; www.usc.edu.ph O.R. SCRUB FORM MAJOR
PAASCU ACCREDITED, LEVEL II, MAY 5, 2008 – MAY 2011

SURGICAL SCRUB in _____________________________________________________

Hospital, Municipality/City/Province

Prepared by:
Printed Name with Signature of Student: ____________________________________

Patient’s INITIALS (only)

Date Performed and O.R. Nurse On Duty SUPERVISED BY
Time Started Case Number SURGICAL PROCEDURE PERFORMED (Name and Signature) Clinical Instructor
(Name and Signature)

Noted by: __________________________________________________________ Approved by: _______________________________________________

(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_________________________________ Specify Highest Nursing Degree Earned_____________________________