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Mindanao Sanitarium & Hospital CollegeSchool of Nursing
Barangay San Miguel, Iligan City 9200Phone No.(063) 221-9219, Fax No. (063) 223-2114, [email protected]
Accredited By: Association of Christian Schools, Colleges and Universities Accrediting Agency, IncorporatedAccreditation Level: Level II, April 29, 2011 – April 2014
Accredited By: Adventist Accrediting AssociationAccreditation Level: Level II, October 4, 2010-December 31, 2012
SURGICAL SCRUB in: Gregorio T. Lluch Memorial Hospital, Palao, Iligan CityAdventist Medical Center, Barangay San Miguel, Iligan CityHospital/Home/Lying-in, Municipality/City/Province
Prepared by:Printed name and Signature of Student: CRISTINA L. JAYSON
Date Performed and
Time Started
Patient’s INITIAL Only
Case Number(not applicable for Birthing/Lying-in
Clinics/Homes)
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty(Name and Signature)
SUPERVISED BYClinical Instructor
Name and Signature
August 9, 201211:30 PM
RB147899
Appendectomy Jed R. Santos, RN, CRNPRC Number: 0660385
Valid Until: July 14, 2016
Darilyn G. Literatus, MN, RNPRC Number: 0301632
Valid Until: November 25, 2016
September 13, 201211:32 AM
SB130179
Pelvic Laparotomy Wendy Mar S. Rodrigo, RNPRC Number: 0313886
Valid Until: March 3, 2015
Sheilma Dreamy G. Manata, MN,RNPRC Number: 0173264
Valid Until: May 28, 2017
December 6, 20121:40 PM
JG062232
First Repeat Low Segment Transverse Cesarean Section
Belen Joy C. Patindol, RNPRC Number: 0306764
Valid Until: December 20, 2015
Sheilma Dreamy G. Manata,MN, RNPRC Number: 0173264
Valid Until: May 28, 2017
Noted by: EVALYN M. LECCIONES, MN, RN Approved by: G’TER G, GAID, PhD, MAN, RN N (Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D No.:0245303 Valid Until:May 9, 2015 Dean, PRC I.D. No.:0302269 Valid Until: September 13, 2015Date document is signed: ________ Time:______________ Date document is signed: Time: ____________________Please specify Highest Nursing Degree Earned: Master in Nursing Please specify Highest Nursing Degree Earned: Master of Arts in Nursing
O.R. Form 1AO.R. SCRUB FORM
MAJOR