bacallan, karen gie s. - ched
TRANSCRIPT
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Name of School:Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
I. MAJOR CASE
No. Case No. Name of Patient Type of Anesthesia
1 10:55 A.M. 11:30 A.M. November 25, 2008 Pascua, Felix Subarachnoid Block
Prepared by: Supervised by: Noted by: Approved by: ConcurreC
KAREN GIE S. BACALLAN MR. AL Z. QUANICO PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. MAXIMA G. MARFIL
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0339365 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0088129
Valid Until : October 29, 2010 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : December 16, 2011
b) PNA No : 046692 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 5730
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834
Valid Until: December 2010
Name of School:Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Time
Started
Time
Ended
Date of
Operation
Operation
Performed
Name of
Surgeon
Name of
Hospital46Chart No.
2008-0099797
Incision and Drainage/ RayAmputation second, third,
fourth toes right foot
Dr. Earl G.Autajay Jr.
Angel SalazarMemorial
General Hospital
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of the ChiefNurse
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Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006Year Graduated from the BSN Program: 2010
I. MAJOR CASE
No. Case No. Name of Patient Type of Anesthesia
2 11:00 A.M. 1:46 P.M. May 4, 2009 31 Napatal, Ariel
3 9:05 A.M. 10:45 A.M. May 5, 2009 45 Rojo, Mark Ken Open Cholecystectomy
4 7:45 A.M. 10:15 A.M. May 6, 2009 55 Emberso, Elena Subarachnoid Block
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN MR. JEFFREY T. UMADHAY PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. FREIDA G. SORONGON
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : MAN
Place : Lapaz Iloilo, City a) PRC No : 321732 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 28836
Valid Until : January 30, 2011 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : August 16, 2011
b) PNA No : Resigned b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 17428
Valid Until : Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834
Valid Until: December 2010
Name of School:Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
TimeStarted
TimeEnded
Date ofOperation
OperationPerformed
Name ofSurgeon
Name ofHospital
Mastoidectomy withtympanoplasty, Left
General EndotrachealTube Anesthesia
Dr. CesarGardose
Western VisayasMedical Center
Subarachnoid Block-epidural
Dr. DelmarBrodeth
Western VisayasMedical Center
Total AbdominalHysterectomy Bilateral
Salpingo Oophorectomy;Adhesiolysis
Adhesiolysis; Ligation ofmesenteric bleeders,Jackson Pratt drain
Dr. Ruphil MaeAnimas-
Dueas andDr. delmar
Brodeth
Western VisayasMedical Center
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of the ChiefNurse
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and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/AAccreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
I. MAJOR CASE
No. Case No. Name of Patient Type of Anesthesia
5 10:30 A.M. 10:52 A.M. February 25, 2010 02-92-96 Arca, Gina Local Anesthesia
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN PROF. JANETTE E. YAP PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : MAN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0230752 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0117016
Valid Until : January 24, 2013 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : November 21, 2010
b) PNA No : 026016 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 1872
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834 c.) ANSAP N 00065
Valid Until: December 2010 Valid Until: December 2010
TimeStarted
TimeEnded
Date ofOperation
OperationPerformed
Name ofSurgeon
Name ofHospital
Bilateral Tubal Ligation( Pomeroy)
Dr. Mary AnnLedesma
Aleosan DistrictHospital
MS. ELIODORA A. BEASSignature over Printed Name of
StudentSignature over Printed Name of
Clinical InstructorSignature over Printed Name of
Clinical CoordinatorSignature over Printed Name of the
DeanSignature over Printed Name of the Chief
Nurse
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Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
II. MINOR CASE
No. Date of Operation Name of Patient Type of Anesthesia
1 9:40 A.M. 10:20 A.M. December 10, 2008 12 Consuelo, Aloro Local Anesthesia
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN MR. AL Z. QUANICO PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. MAXIMA G. MARFIL
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0339365 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0088129
Valid Until : October 29, 2010 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : December 16, 2011
b) PNA No : 046692 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 5730
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member ADPCN No. 0834
Valid Until: December 2010
TimeStarted
TimeEnded
CaseNo.
OperationPerformed
Name ofSurgeon
Name ofHospital
Excision of sebaceous cystat left elbow
Dr. GraceMajaducon-
Alvarez
Angel SalazarMemorialGeneralHospital
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse
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Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
II. MINOR CASE
No. Date of Operation Name of Patient Type of Anesthesia
2 2:30 P.M. 2:45 P.M. September 8, 2009 22132 Lavilla, Raffy Local Anesthesia
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN MRS. NENIT S. SOLDEVILLA PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. CECILIA L. LOSARIA
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0114283 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0049663Valid Until : March 5, 2013 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : November 22, 2012
b) PNA No : 048612 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 16705
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834 c. ANSAP No. 02935
TimeStarted
TimeEnded
CaseNo.
OperationPerformed
Name ofSurgeon
Name ofHospital
Suturing 0f wound andligation of bleeder left
thumb
Dr. AliciaCordero
Dr. Ricardo YLadrido
MemorialHospital
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse
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8/7/2019 Bacallan, Karen Gie S. - CHED
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Valid Until: December 2010 Valid Until: December 31, 2010
Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
II. MINOR CASE
No. Date of Operation Name of Patient Type of Anesthesia
3 10:35 A.M. 10:57 A.M. March 12, 2010 01-76-05 Camarista, Mariano Local Anesthesia
4 11:07 A.M. 11:16 A.M. March 12, 2010 5-18--56 Alquisada, Vicente Jr. Local Anesthesia
Prepared by: Supervised by: Noted by: Approved by: Supervised by:
KAREN GIE S. BACALLAN PROF JANETTE E. YAP PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : MAN Degree : MAN Degree : BSN, RN, MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0230752 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0117016
Valid Until : January 24, 2013 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : November 21, 2010b) PNA No : 026016 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 1872
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834 c. ANSAP No. 00065
Valid Until: December 2010 Valid Until: December 2010
TimeStarted
TimeEnded
CaseNo.
OperationPerformed
Name ofSurgeon
Name ofHospital
Excision of sebaceous cystat occipital area
Dr. PaulChristopher
Lim
Aleosan DistrictHospital
Cauterization of warts atleft big toe
Dr. PaulChristopher
Lim
Aleosan DistrictHospital
MS. ELIODORA A. BEAS
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse
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Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
II. MINOR CASE
No. Date of Operation Name of Patient Type of Anesthesia
5 1:50 P.M. 2:10 P.M. March 15, 2010 2010-1726 Gabinete, Vicente Local Anesthesia
Prepared by: Supervised by: Noted by: Approved by: Supervised by:
KAREN GIE S. BACALLAN MRS. ROSEMARIE D. CRISPE PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. LIBERTY T. TRABADO
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : BSN, RN, MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0067242 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0149875Valid Until : August 24, 2011 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : September 4, 2011
b) PNA No : 1896 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 11322
Valid Until : Lifetime Member Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834 c. ANSAP No. 12301
TimeStarted
TimeEnded
CaseNo.
OperationPerformed
Name ofSurgeon
Name ofHospital
Suturing of laceratedwound at left elbow
Dr. SocratesCuarte
Ramon TabianaMemorial
District Hospital
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse
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8/7/2019 Bacallan, Karen Gie S. - CHED
8/15
Valid Until: December 2010 Valid Until: December 31,
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8/7/2019 Bacallan, Karen Gie S. - CHED
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Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
III. ACTUAL DELIVERIES
No. Diagnosis Name of Mother Age Name of Hospital
1 21856 Pasan, Jona Mae 12:37 P.M. Male
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN MRS. NENIT S. SOLDEVILLA PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. CECILIA L. LOSARIA
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0114283 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0049663
Valid Until : March 5, 2013 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : November 22, 2012b) PNA No : 048612 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 16705
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834 c. ANSAP No. 02935
Valid Until: December 2010 Valid Until: December 31, 2010
CaseNumber
Date ofDelivery
Time ofDelivery
Genderof Baby
Type ofDelivery
Pregnancy Uterine FullTerm delivered to a live
baby boy via NormalSpontaneous Vaginal
Delivery
23 yearsold
September 9,2009
Dr. Ricardo Y Ladrido MemorialHospital
NormalSpontaneous
Vaginal Delivery
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse
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Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
IV. DELIVERIES ASSISTED
No. Diagnosis Name of Mother Age Name of Hospital
1 Oliveros, Cora October 25,2009 9:30 P.M. Male
2 Sanicolas, Joan October 25, 2009 11:32 P.M. Female
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN MRS. MARIA ROSITA N. SALDAJENO PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. MAXIMA G. MARFIL
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0200979 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0088129Valid Until : October 2, 2011 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : December 16, 2011
b) PNA No : 026035 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 5730
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
ADPCN No. 0834
CaseNumber
Date ofDelivery
Time ofDelivery
Genderof Baby
Type ofDelivery
186Chart Number:
2006-0060736
Pregnancy Uterine Full Termdelivery via Normal Spontaneous
Vaginal Delivery to a live baby boyin Cephalic presentation. Birth
Weight 2.8 kilograms, Gravida10
Para10(100010)
42 yearsold
Angel Salazar Memorial GeneralHospital
NormalSpontaneous
Vaginal Delivery
188Chart Number:
2008-0098021
Pregnancy Uterine Full Termdelivery via Normal Spontaneous
Vaginal Delivery to a live girl boy in
Cephalic presentation. Birth Weight2.5 kilograms, Gravida 3 Para1
(3001)
32 years
old
Angel Salazar Memorial General
Hospital
Normal
SpontaneousVaginal Delivery
Signature over Printed Name ofStudent
Signature over Printed Name of ClinicalInstructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse
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Valid Until: December 2010
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Name of School: Central Philippine University SPECIFIED FORMS & SCRUBS
Address: Jaro, Iloilo City As Per PRC Resolution No. 357 Series 2004
and PRC-BON Memorandum No. 01, S. 2008
Name of Student: Bacallan, Karen Gie Sumpio First Course (If any) : N/A Year: N/A
Date School/Program was Recognized: July 1, 1951 School Graduated From: N/A
Accreditation Level: II Year of Admission in the BSN Program: 2006
Year Graduated from the BSN Program: 2010
V. CORD DRESSING
No. Date Performed Time of Delivery Gender of Baby Name of Mother Age Name of Hospital
1 22279 September 14, 2009 12:58 P.M. Female Daniel, Sol Dr. Ricardo Y Ladrido Memorial Hospital
2 22474 September 23, 2009 5:16 P.M. Female Dellomes, Yvonne Dr. Ricardo Y Ladrido Memorial Hospital
Prepared by: Supervised by: Noted by: Approved by: Concurred by:
KAREN GIE S. BACALLAN MRS. NENIT S. SOLDEVILLA PROF. CECILIA B. ARCENAS PROF. FAITH LEILA A. QUEROL MRS. CECILIA L. LOSARIA
CTC Number : 27816636 Date Signed : Date Signed : Date Signed : Date Signed :
Date : June 23,2010 Degree : BSN Degree : MAN Degree : MAN Degree : BSN
Place : Lapaz Iloilo, City a) PRC No : 0114283 a) PRC No : 0036554 a) PRC No : 0120918 a) PRC No : 0049663
Valid Until : March 5, 2013 Valid Until : July 7, 2011 Valid Until : May 20, 2012 Valid Until : November 22, 2012
b) PNA No : 048612 b) PNA No : 026006 b) PNA No : 9317 b) PNA No : 16705
Valid Until : October 31, 2010 Valid Until : October 31, 2010 Valid Until : Lifetime Member Valid Until : Lifetime Member
c) ADPCN No. 0834 c) ANSAP No: 02935
Valid Until: December 2010 Valid Until: December 31, 2010
CaseNumber
29 yearsold
27 yearsold
Signature over Printed Name ofStudent
Signature over Printed Name ofClinical Instructor
Signature over Printed Name ofClinical Coordinator
Signature over Printed Name of theDean
Signature over Printed Name of theChief Nurse