prc cases form
TRANSCRIPT
COLLEGE OF OUR LADY OF MT. CARMELKm. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing
Name of Student: ____________________ Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____ Accreditation Level (if any): N/A Year Granted: N/A ____ Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____ First Course (if any) : ____ School Graduated From: Year: ____________________ Year of Admission in the Bachelor of Science in Nursing Program: ____ Year Graduated (BSN Program): ____________
I. MAJOR OPERATIONS
No.Date of
OperationCase No.
Name of Patient Diagnosis Operation PerformedType of
AnesthesiaName of Surgeon Name of Hospital Name of OR Scrub Nurse
Signature of OR Scrub
Nurse
1
2
3
4
5
Concurred by: Concurred by: Approved by:
Chief Nurse, Our Lady of Mt. Carmel Medical CenterDate Signed: _____________________________Degree: _____ _______________ _____________
a. PRC No.: _______________________Valid Until: _____ ________________
b. PNA No.: _____ __________ Valid Until: _____ ___________
c. ANSAP No.: _____________________ Valid Until: _____ ___________
Chief Nurse, Romana Pangan District HospitalDate Signed: ________________________________Degree: ____ __________________
a. PRC No.: _____ __________Valid Until: _____ __________
b. PNA No.: _____ _________________ Valid Until: _______________ _________ c. ANSAP No.: ________________________ Valid Until: _____ ______________
__________________________________________________
Dean, College of Nursing College of Our Lady of Mt. Carmel (Pampanga) Date Signed: __________________________________ Degree: __________________________________ a. PRC No.: ______________________________ Valid Until: _____________________________
b. PNA No.: ______________________________ Valid Until: ______________________________ c. ANSAP No.: ___________________________ Valid Until: _____ _____________________
Noted by:
_____________________________________________
Clinical CoordinatorDate Signed: __________________________________Degree: ____________________________________ a. PRC No.: _____________________________ Valid Until: ____________________________
b. PNA No.: ____________________________ Valid Until: ____________________________ c. ANSAP No.: _______________________
Prepared by:____________________________________
Student Nurse
_________________________________________
Chief Nurse, Date Signed: _____________________________Degree: _____ _______________ _____________
a. PRC No.: _______________________Valid Until: _____ ________________
b. PNA No.: _____ __________ Valid Until: _____ ___________ c. ANSAP No.: ____________________ Valid Until: _____ __________
COLLEGE OF OUR LADY OF MT. CARMELKm. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing
Name of Student: ____________________ Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____ Accreditation Level (if any): N/A Year Granted: N/A ____ Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____ First Course (if any) : ____ School Graduated From: Year: ____________________ Year of Admission in the Bachelor of Science in Nursing Program: ____ Year Graduated (BSN Program): ____________
II. MINOR OPERATIONS
No.Date of
OperationCase No. Name of Patient Diagnosis Operation Performed
Type of Anesthesia
Name of Surgeon Name of Hospital Name of OR Scrub NurseSignature of
OR Scrub Nurse
1
2
3
4
5
Concurred by Concurred by: Concurred by: Approved by:
_________________________________________
Chief Nurse, Our Lady of Mt. Carmel Medical CenterDate Signed: _____________________________Degree: _____ _______________ _____________
a. PRC No.: _______________________Valid Until: _____ ________________
b. PNA No.: _____ __________ Valid Until: _____ ___________ c. ANSAP No.: ____________________ Valid Until: _____ __________
_______________________________________________ _____________________________________
Chief Nurse, Porac District Hospital Dean, College of NursingDate Signed: ____________________________________ College of Our Lady of Mt. Carmel (Pampanga)Degree: _____ __________________________ Date Signed: __________________________________ a. PRC No.: _____ ______________________ Degree: __________________________________ Valid Until: _______________________________ a. PRC No.: _____________________________ b. PNA No.: _____ _____________________ Valid Until: ____________________________ Valid Until: _____ _____________________ _ b. PNA No.: ______________________________ c. ANSAP No.: _____________________________ Valid Until: _____________________________ Valid Until: _____ __________________ c. ANSAP No.: ____________________________ Valid Until: _____ _________________
Noted by:
______________________________________________
Clinical CoordinatorDate Signed: __________________________________Degree: ____________________________________ a. PRC No.: _____________________________ Valid Until: ____________________________ b. PNA No.: _____________________________ Valid Until: ____________________________ c. ANSAP No.: __________________________
Valid Until: _____ _________________
Prepared by:____________________________________
Student Nurse
COLLEGE OF OUR LADY OF MT. CARMELKm. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing
Name of Student: ____________________ Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____ Accreditation Level (if any): N/A Year Granted: N/A ____ Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____ First Course (if any) : ____ School Graduated From: Year: ____________________ Year of Admission in the Bachelor of Science in Nursing Program: ____ Year Graduated (BSN Program): ____________
III. ACTUAL DELIVERIES
No.Case No.
Diagnosis Name of Mother AgeDate of Delivery
Time of Delivery
Gender of Baby
Name of Hospital Type of DeliverySupervised by: Name and
Signature of Qualified Clinical Instructor
1
2
3
4
5
Concurred by: Concurred by: Concurred by: Approved by:
_________________________________________Trinidad YambingChief Nurse, Date Signed: _____________________________Degree: _____ _______________ _____________
a. PRC No.: _______________________Valid Until: _____ ________________
b. PNA No.: _____ __________ Valid Until: _____ ___________ c. ANSAP No.: ____________________ Valid Until: _____ __________
_________________________________________Chief Nurse, Date Signed: _____________________________Degree: _____ _______________ _____________
c. PRC No.: _______________________Valid Until: _____ ________________
d. PNA No.: _____ __________ Valid Until: _____ ___________ c. ANSAP No.: ____________________ Valid Until: _____ __________
_______________________________________________ __________________________________________________
Chief Nurse, Dean, College of NursingDate Signed: ____________________________________ College of Our Lady of Mt. Carmel (Pampanga)Degree: _____ __________________________ Date Signed: __________________________________ a. PRC No.: _____ ______________________ Degree: __________________________________ Valid Until: _______________________________ a. PRC No.: _____________________________ b. PNA No.: _____ _____________________ Valid Until: ____________________________ Valid Until: _____ _____________________ _ b. PNA No.: _____________________________ c. ANSAP No.: ____________________ _________ Valid Until: _____________________________ Valid Until: _____ __________________ c. ANSAP No.: ___________________________ Valid Until: _____ __________________ ____________________________
Noted by:
______________________________________________
Clinical CoordinatorDate Signed: __________________________________Degree: ____________________________________ a. PRC No.: _____________________________ Valid Until: ____________________________ b. PNA No.: _____________________________ Valid Until: ____________________________ c. ANSAP No.: ___________________________
Valid Until: _____ _________________
Prepared by:____________________________________
Student Nurse
COLLEGE OF OUR LADY OF MT. CARMELKm. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing
Name of Student: ________________ Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ Accreditation Level (if any): N/A Year Granted: N/A Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 First Course (if any) : ____ School Graduated From: Year: ________________ Year of Admission in the Bachelor of Science in Nursing Program: Year Graduated (BSN Program):
IV. DELIVERIES ASSISTED
No.Case No.
Diagnosis Name of Mother AgeDate of Delivery
Time of Delivery
Gender of Baby
Name of HospitalType of Delivery
Supervised by:Name & Signiture of C.I.
1
2
3
4
5
Concurred by: Concurred by: Approved by:
___________________________________________
Chief Nurse, Our Lady of Mt. Carmel Medical CenterDate Signed: ________________________________Degree: ____ __________________
a. PRC No.: _____ __________Valid Until: _____ __________
b. PNA No.: _____ _________________ Valid Until: _______________ _________ c. ANSAP No.: _______________________ Valid Until: _____ ______________
_______________________________________________ ________________________________________
Chief Nurse, Romana Pangan District Hospital Dean, College of NursingDate Signed: ____________________________________ College of Our Lady of Mt. Carmel (Pampanga)Degree: _____ __________________________ Date Signed: __________________________________ a. PRC No.: _____ ______________________ Degree: __________________________________ Valid Until: _______________________________ a. PRC No.: _____________________________ b. PNA No.: _____ _____________________ Valid Until: ____________________________ Valid Until: _____ _____________________ _ b. PNA No.: ______________________________ c. ANSAP No.: ____________________ Valid Until: ____________________________ Valid Until: _____ __________ c. ANSAP No.: ___________________________ Valid Until: _____ __________________
Noted by:
______________________________________________
Clinical CoordinatorDate Signed: __________________________________Degree: ____________________________________ a. PRC No.: _____________________________ Valid Until: ____________________________ b. PNA No.: _____________________________ Valid Until: ____________________________
c. ANSAP No.: ___________________________ Valid Until: _____ _________________
Prepared by:____________________________________
Student Nurse
COLLEGE OF OUR LADY OF MT. CARMELKm. 78 Mc. Arthur Highway, Brgy Saguin, City of San Fernando, (Pampanga)
College of Nursing
Name of Student: ____________________ Name & Address of School: College of Our Lady of Mt. Carmel, Km 78 mc. Arthur Highway, Brgy. Saguin, City of San Fernando (Pampanga)_ _ ____ Accreditation Level (if any): N/A Year Granted: N/A ____ Date School/Program is Recognized: Government Recognition Number: HER-021 Year: March 27, 2008 ____ First Course (if any) : ____ School Graduated From: Year: ____________________ Year of Admission in the Bachelor of Science in Nursing Program: ____ Year Graduated (BSN Program): ____________
V. CORD DRESSING
No. Case No.Date
PerformedName of Baby
Gender of Baby
Name of Mother Age Name of Hospital Supervised by: Name and Signature of Qualified C.I.
1
2
3
4
5
Concurred by: Concurred by: Approved by:
_________________________________________
Chief Nurse, Romana Pangan District HospitalDate Signed: _____________________________Degree: _____ _______________ _____________
a. PRC No.: _______________________Valid Until: _____ ________________
b. PNA No.: _____ __________ Valid Until: _____ ___________
___________________________________________
Chief Nurse, Date Signed: ________________________________Degree: ____ __________________
a. PRC No.: _____ __________Valid Until: _____ __________
b. PNA No.: _____ _________________ Valid Until: _______________ _________ c. ANSAP No.: ________________________ Valid Until: _____ _________________
__________________________________________________
Dean, College of NursingCollege of Our Lady of Mt. Carmel (Pampanga)Date Signed: __________________________________ Degree: ________________________________ a. PRC No.: _____________________________ Valid Until: ____________________________ b. PNA No.: _____________________________ Valid Until: _____ _________________ c. ANSAP No.: ___________________________ Valid Until: _____ ________________
Noted by:
______________________________________________
Clinical CoordinatorDate Signed: __________________________________Degree: ____________________________________ a. PRC No.: _____________________________ Valid Until: ____________________________ b. PNA No.: _____________________________ Valid Until: ____________________________
c. ANSAP No.: ________________________ Valid Until: _____ _________________
Prepared by:____________________________________
Student Nurse
