Prepared by:

STUDENT

LEGEND:

Concurred by:

JULITA M. LATOSQUINSignature Over printed name of CHIEF NURSEDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Approved By:

Signature Over printed name of DEANDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:c). ADPCN No.: Valid Until:

Noted by:

Signature Over printed name of RLE COORDINATORDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Name of Student: SURNAME, GIVEN NAME MIDDLE NAMEName & Address of School: Manila Doctors College, President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay CityAccreditation Level (if any): PAASCU Level II Re-accredited Status Year Granted: January 31, 2009 to November 2011Date School/Program was Recognized: July 6, 1981 Number: 098 Year: 1981First Course (if any): Not Applicable School Graduated From: Not ApplicableYear of Admission in the Bachelor of Science in Nursing Program: 2007Year Graduated (BSN Program): 2011

MAJOR OPERATIONS

No.Date of

OperationCase No.

Name of Patient

DiagnosisOperation Performed

Type of Anesthesia

Name of Surgeon

Name of Hospital

Supervised by:Name of Qualified Clinical Instructor

PRCID #

Date of Validity

PNA ID #

Date of Validity

Signature of Qualified Clinical

Instructor

1.

2.

3.

4.

5.

Prepared by:

STUDENT

LEGEND: Hospital

Concurred by:

JULITA M. LATOSQUINSignature Over printed name of CHIEF NURSEDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Approved By:

Signature Over printed name of DEANDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:c). ADPCN No.: Valid Until:

Noted by:

Signature Over printed name of RLE COORDINATORDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Name of Student: SURNAME, GIVEN NAME MIDDLE NAMEName & Address of School: Manila Doctors College, President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay CityAccreditation Level (if any): PAASCU Level II Re-accredited Status Year Granted: January 31, 2009 to November 2011Date School/Program was Recognized: July 6, 1981 Number: 098 Year: 1981First Course (if any): Not Applicable School Graduated From: Not ApplicableYear of Admission in the Bachelor of Science in Nursing Program: 2007Year Graduated (BSN Program): 2011

MINOR OPERATIONS

No.Date of

OperationCase No.

Name of Patient

DiagnosisOperation Performed

Type of Anesthesia

Name of Surgeon

Name of Hospital

Supervised by:Name of Qualified Clinical Instructor

PRCID #

Date of Validity

PNA ID #

Date of Validity

Signature of Qualified Clinical

Instructor

1.

2.

3.

4.

5.

Prepared by:

STUDENT

LEGEND:

Concurred by:

JULITA M. LATOSQUINSignature Over printed name of CHIEF NURSEDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Approved By:

Signature Over printed name of DEANDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:c). ADPCN No.: Valid Until:

Noted by:

Signature Over printed name of RLE COORDINATORDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Name of Student: SURNAME, GIVEN NAME MIDDLE NAMEName & Address of School: Manila Doctors College, President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay CityAccreditation Level (if any): PAASCU Level II Re-accredited Status Year Granted: January 31, 2009 to November 2011Date School/Program was Recognized: July 6, 1981 Number: 098 Year: 1981First Course (if any): Not Applicable School Graduated From: Not ApplicableYear of Admission in the Bachelor of Science in Nursing Program: 2007Year Graduated (BSN Program): 2011

ACTUAL DELIVERIES

No. Case No. DiagnosisName of Mother

AgeDate of

DeliveryTime of Delivery

Gender of Baby

Name of HospitalType of Delivery

Supervised by:Name of Qualified Clinical Instructor

PRC ID #

Date of Validity

PNA ID #

Date of Validity

Signature of Qualified Clinical

Instructor

1.

2.

3.

4.

5.

Prepared by:

STUDENT

LEGEND:

Concurred by:

Signature Over printed name of CHIEF NURSEDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Approved By:

Signature Over printed name of DEANDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:c). ADPCN No.: Valid Until:

Noted by:

Signature Over printed name of CLINICAL COORDINATORDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Name of Student: SURNAME, GIVEN NAME MIDDLE NAMEName & Address of School: Manila Doctors College, President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay CityAccreditation Level (if any): PAASCU Level II Re-accredited Status Year Granted: January 31, 2009 to November 2011Date School/Program was Recognized: July 6, 1981 Number: 098 Year: 1981First Course (if any): Not Applicable School Graduated From: Not ApplicableYear of Admission in the Bachelor of Science in Nursing Program: 2007Year Graduated (BSN Program): 2011

DELIVERY ASSISTED

No. Case No. Diagnosis Name of Mother AgeDate of

DeliveryTime of Delivery

Gender of Baby

Name of Hospital

Type of Delivery

Supervised by:Name of Qualified Clinical Instructor

PRC ID #

Date of Validity

PNA ID #

Date of Validity

Signature of Qualified Clinical

Instructor

1.

2.

3.

4.

5.

Approved by:

Norma M. DumadagDean, College of NursingManila Doctors CollegeDate Signed: ___________Degree: RN, MN a. PRC No.: 0018659 Valid Until: December 29, 2011b. PNA No.: 5350Valid Until: Lifetimec. ADPCN: 0802Valid Until: October 2009

Prepared by:

STUDENT

LEGEND:

Concurred by:

Signature Over printed name of CHIEF NURSEDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Approved By:

Signature Over printed name of DEANDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:c). ADPCN No.: Valid Until:

Noted by:

Signature Over printed name of CLINICAL COORDINATORDate Signed:Degree:a). PRC No.: Valid Until:b). PNA No.: Valid Until:

Name of Student: SURNAME, GIVEN NAME MIDDLE NAMEName & Address of School: Manila Doctors College, President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay CityAccreditation Level (if any): PAASCU Level II Re-accredited Status Year Granted: January 31, 2009 to November 2011Date School/Program was Recognized: July 6, 1981 Number: 098 Year: 1981First Course (if any): Not Applicable School Graduated From: Not ApplicableYear of Admission in the Bachelor of Science in Nursing Program: 2007Year Graduated (BSN Program): 2011

CORD CARE

No.Case No.

Date Performed

Name of BabyGender of

BabyName of Mother Age

Name of Hospital

Supervised by:Name of Qualified Clinical Instructor

PRC ID #

Date of Validity

PNA ID #

Date of Validity

Signature of Qualified Clinical

Instructor

1.

2.

3.

4.

5.