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UNIVERSITY OF LA SALETTE Major casesBACHELOR ST.,DUBINAN EAST, SANTIAGO CITY
SURGICAL SCRUB in____________________________________________________________
Prepared by:
Date Performed and Time Started
Patients Initials CASE NUMBER
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor (Name and Signature)
Noted by:____________________________________________________ Approved by: _______________________________________Clinical Coordinator, PRC I.D no. _________ Valid Until______________ Dean, PRC I.D. No. _____________ Valid Until:________________ Date Document is signed: ________________ Time: _____________ ADPCN No. __________________ Valid Until:_________________Please specify Highest Nursing Degree Earned:__________________________ Date document is signed: _______________ Time: ___________ Specify Highest Nursing Degree Earned:______________________
UNIVERSITY OF LA SALETTE Minor casesBACHELOR ST.,DUBINAN EAST, SANTIAGO CITY
SURGICAL SCRUB in____________________________________________________________
Prepared by:
Date Performed and Time Started
Patients Initials CASE NUMBER
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor (Name and Signature)
Noted by:____________________________________________________ Approved by: _______________________________________Clinical Coordinator, PRC I.D no. _________ Valid Until______________ Dean, PRC I.D. No. _____________ Valid Until:________________ Date Document is signed: ________________ Time: _____________ ADPCN No. __________________ Valid Until:_________________Please specify Highest Nursing Degree Earned:__________________________ Date document is signed: _______________ Time: ___________ Specify Highest Nursing Degree Earned:______________________
UNIVERSITY OF LA SALETTE HANDLEBACHELOR ST.,DUBINAN EAST, SANTIAGO CITY
SURGICAL SCRUB in____________________________________________________________
Prepared by:
Date Performed and Time Started
Patients Initials CASE NUMBER
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor (Name and Signature)
Noted by:____________________________________________________ Approved by: _______________________________________Clinical Coordinator, PRC I.D no. _________ Valid Until______________ Dean, PRC I.D. No. _____________ Valid Until:________________ Date Document is signed: ________________ Time: _____________ ADPCN No. __________________ Valid Until:_________________Please specify Highest Nursing Degree Earned:__________________________ Date document is signed: _______________ Time: ___________ Specify Highest Nursing Degree Earned:______________________
UNIVERSITY OF LA SALETTE ASSISTEDBACHELOR ST.,DUBINAN EAST, SANTIAGO CITY
SURGICAL SCRUB in____________________________________________________________
Prepared by:
Date Performed and Time Started
Patients Initials CASE NUMBER
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor (Name and Signature)
Noted by:____________________________________________________ Approved by: _______________________________________Clinical Coordinator, PRC I.D no. _________ Valid Until______________ Dean, PRC I.D. No. _____________ Valid Until:________________ Date Document is signed: ________________ Time: _____________ ADPCN No. __________________ Valid Until:_________________Please specify Highest Nursing Degree Earned:__________________________ Date document is signed: _______________ Time: ___________ Specify Highest Nursing Degree Earned:______________________
UNIVERSITY OF LA SALETTE CORD CAREBACHELOR ST.,DUBINAN EAST, SANTIAGO CITY
SURGICAL SCRUB in____________________________________________________________
Prepared by:
Date Performed and Time Started
Patients Initials CASE NUMBER
SURGICAL PROCEDURE PERFORMED
O.R. Nurse on Duty (Name and Signature)
SUPERVISED BY: Clinical Instructor (Name and Signature)
Noted by:____________________________________________________ Approved by: _______________________________________Clinical Coordinator, PRC I.D no. _________ Valid Until______________ Dean, PRC I.D. No. _____________ Valid Until:________________ Date Document is signed: ________________ Time: _____________ ADPCN No. __________________ Valid Until:_________________Please specify Highest Nursing Degree Earned:__________________________ Date document is signed: _______________ Time: ___________ Specify Highest Nursing Degree Earned:______________________