summary cmo 14

TRACE COLLEGEEl Danda Street, Batong Malake, Los Baños, Laguna

Telephone no. (049) 536-3944, Fax (049) 536-1425, Web-Site www.tracecollege.edu.phSURGICAL SCRUB in ____________________________________________________________________________________

Hospital, Municipality/City/Province

Prepared by:Printed Name with Signature of Student: _____________________________________________

Date Performed and

Time Started

Patient’s INITIALS only

Case NumberSURGICAL PROCEDURE

PERFORMED

O.R. Nurse on Duty (Name AND Signature)

SUPERVISED BYClinical Instructor

Name and Signature

Prepared by:Printed Name with Signature of Student: _____________________________________________

Date Performed and

Time Started

Patient’s INITIALS only

Case NumberSURGICAL PROCEDURE

PERFORMED

O.R. Nurse on Duty (Name AND Signature)

SUPERVISED BYClinical Instructor

Name and Signature

(STRICTLY NO DESIGNATES)

O.R. Form 1AO.R. SCRUB FORM

Major

O.R. Form 1BO.R. CIRCULATING

FORM

TRACE COLLEGEEl Danda Street, Batong Malake, Los Baños, Laguna

Telephone no. (049) 536-3944, Fax (049) 536-1425, Web-Site www.tracecollege.edu.phACTUAL DELIVERY in ____________________________________________________________________________________

Hospital/ Home/ Lying-In Clinic, Municipality/City/ProvincePrepared by:Printed Name with Signature of Student: _____________________________________________

Date Performed and

Time Started

Patient’s INITIALS only

Case Number(not applicable for Birthing/Lying-In

Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and Signature

IMMEDIATE NEWBORN CORD CARE in ____________________________________________________________________ Hospital/ Home/ Lying-In Clinic, Municipality/City/Province

Prepared by:Printed Name with Signature of Student: _____________________________________________

Date Performed and

Time Started

Patient’s INITIALS only

Case Number(not applicable for Birthing/Lying-In

Clinics/Homes)

Immediate Newborn Cord Care

PERFORMED

O.R. Nurse on Duty(Name AND Signature)

SUPERVISED BYClinical Instructor

Name and Signature

(STRICTLY NO DESIGNATES)

ICNB FormIMMEDIATE CARE OF THE

NEWBORN FORM

D

D.R. Form

ACTUAL DELIVERY Form