prc form_ or
TRANSCRIPT
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ANDRES BONIFACIO COLLEGECollege Park, Dipolog City, Philippines
Telephone No.(065) 212-9776/ Fax No. (065) 212-9178 / web-site: www.abcollege.edu.ph
Name of Student: CHARLITO C. LUAB JR.
SUMMARY OF MAJOR OPERATIONS ASSISTED (Scrub Nurse)
No.
Date of
Operationand
Time
Assisted
CaseNo.
Name
ofPatients
Initial(only)
DiagnosisOperationPerformed
Typeof
Anesthesia
Nameof
Surgeon
Nameof
Hospital
Name and Signatureof
O. R. Nurse
Supervised by:Name and Signature of C. I
1.
August 16,2012
4:59 P.M.
03-29-
38A. U.
Pregnancy uterinefull term 36 weeks
age of gestationplacenta previa
Primary lowsegment
transverse
cesarean sectionwith bilateral
tubal ligation
Spinal
Anesthesia
Dr.
Norman G.Silao
ZDSMCThelma A. Apatan, R.N.,
M.N., MPA
Shmesani Marie A. Alavanza
BSN, R.N., M.N.
2.
November
15, 20128:55 P.M.
03-74-64
M. G. Ectopic pregnancyPelvic laparotomy
right salpingo-
oophorectomy
SpinalAnesthesia
Dr. AvenidaVista
ZDSMC Thelma A. Apatan, R.N.,
M.N., MPA
Shmesani Marie A. Alavanza
BSN, R.N., M.N.
3.
November
17, 201210:40 A.M.
03-39-
92M. G. Prolapsed submucous
uterine myomaVaginal
MyomectomyGeneral
Anesthesia
Dr.
Norman G.Silao
ZDSMCThelma A. Apatan, R.N.,
M.N., MPAShmesani Marie A. Alavanza
BSN, R.N., M.N.
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ANDRES BONIFACIO COLLEGECollege Park, Dipolog City, Philippines
Telephone No.(065) 212-9776/ Fax No. (065) 212-9178 / web-site: www.abcollege.edu.phCommission on Higher Education Region IX, Zamboanga Peninsula Government Recognition No. 002 Series of 2006
SURGICAL SCRUB in Zamboanga del Sur Medical Center, Pagadian City, Zamboanga del SurHospital/Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: CHARLITO C. LUAB JR.
Date Performed
andTime Started
Patients Initial
(only)
Case Number
SURGICAL PROCEDURE PERFORMED O. R. Nurse on Duty
SUPERVISED BY:
Clinical InstructorName and Signature
August 16,
20124:59 P.M.
A. U.03-29-38
Primary low segment transversecesarean section with bilateral
tubal ligationThelma M. Apatan, R.N., M.N., MPA Shmesani Marie A. Alavanza, BSN, R.N., M.N.
November 15,2012
8:55 P.M.
M. G.03-74-64
Pelvic laparotomy right salpingo-oophorectomy
Thelma M. Apatan, R.N., M.N., MPA Shmesani Marie A. Alavanza, BSN, R.N., M.N.
November 17,
201210:40 A.M.
M. G.
03-39-92Vaginal Myomectomy Thelma M. Apatan, R.N., M.N., MPA Shmesani Marie A. Alavanza, BSN, R.N., M.N.
Noted by: SHARON B. CABIGAS, R.N., M.N. Approved by: EVELYN A. LUNA, R.N., MPHClinical Coordinator, PRC I.D. No. 0349540Valid Until: March 16, 2013 Dean, PRC I.D. No. 0082222Valid Until: May 31, 2015Date Document is signed: Time: Date Document is signed: Time: _____________
Please Specify Highest Nursing Degree Earned: Master in Nursing Please Specify Highest Nursing Degree Earned: Master in Public Health
O. R. Form 1AO. R. SCRUB FORM
Major
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ANDRES BONIFACIO COLLEGE
College Park, Dipolog City, PhilippinesTelephone No.(065) 212-9776/ Fax No. (065) 212-9178 / web-site: www.abcollege.edu.ph
Name of Student: CHARLITO C. LUAB JR.
SUMMARY OF MAJOR OPERATIONS ASSISTED (Circulating Nurse)
No.
Date of
Operationand
Time
Assisted
CaseNo.
Name
ofPatients
Initial(only)
DiagnosisOperationPerformed
Typeof
Anesthesia
Nameof
Surgeon
Nameof
Hospital
Name and Signatureof
O. R. Nurse
Supervised by:Name and Signature of C. I.
1.
May 22,2012
11:42A.M.
02-79-
17R. C. Cleft Palate Cheiloplasty
Local
Anesthesia
Dr.Joseph
Acosta/D
r. AuritoC.
Ampong
ZDSMC Thelma M. Apatan, R.N.,M.N., MPA
Shmesani Marie A. Alavanza, BSN,R.N., M.N.
2.
May 22,2012
6:40 P.M.
02-78-
63P. B.
Anterior neck
nodes withcolloidal
adenomatous
goiter
Subtotal
thyroidectomy
General
Anesthesia
Dr. Eric
Talens/Dr. Al
Jamiri
Radjid
ZDSMCThelma M. Apatan, R.N.,
M.N., MPA
Shmesani Marie A. Alavanza, BSN,
R.N., M.N.
3.
May 22,
201210:48P.M.
02-78-69
S. A. CalculousCholecystitis
CholecystectomyGeneral
Anesthesia
Dr. Eric
Talens/Dr. Al
Jamiri
Radjid
ZDSMCThelma M. Apatan, R.N.,
M.N., MPAShmesani Marie A. Alavanza, BSN,
R.N., M.N.
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ANDRES BONIFACIO COLLEGECollege Park, Dipolog City, Philippines
Telephone No.(065) 212-9776/ Fax No. (065) 212-9178 / web-site: www.abcollege.edu.phCommission on Higher Education Region IX, Zamboanga Peninsula Government Recognition No. 002 Series of 2006
SURGICAL SCRUB in Zamboanga del Sur Medical Center, Pagadian City, Zamboanga del SurHospital/Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: CHARLITO C. LUAB JR.
Date Performed
andTime Started
Patients Initial
(only)
Case Number
SURGICAL PROCEDURE PERFORMED O. R. Nurse on Duty
SUPERVISED BY:
Clinical InstructorName and Signature
May 22, 2012
11:42 A.M.R. C.
02-79-17Cheiloplasty Thelma A. Apatan, R.N., M.N., MPA Shmesani Marie A. Alavanza, BSN, R.N.,
M.N
May 22, 20126:40 P.M.
P. B.
02-78-63Subtotal thyroidectomy Thelma A. Apatan, R.N., M.N., MPA Shmesani Marie A. Alavanza, BSN, R.N.,
M.N.
May 22, 201210:48 P.M.
S. A.02-78-69
Cholecystectomy Thelma A. Apatan, R.N., M.N., MPA Shmesani Marie A. Alavanza, BSN, R.N.,
M.N.
Noted by: SHARON B. CABIGAS, R.N., M.N. Approved by: EVELYN A. LUNA, R.N., MPHClinical Coordinator, PRC I.D. No. 0349540Valid Until: March 16, 2013 Dean, PRC I.D. No. 0082222Valid Until: May 31, 2015Date Document is signed: Time: Date Document is signed: Time:
Please Specify Highest Nursing Degree Earned: Master in Nursing Please Specify Highest Nursing Degree Earned: Master in Public Health
O. R. Form 1BO. R. CIRCULATING
FORM
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