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 JOSE RIZAL UNIVERSITY 80 Shaw Boulevard, Mandaluyong City

Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu

www.jru.edu.ph

IMMEDIATE NEWBORN CORD CARE in _____ San Juan Medical Center, San Juan City__________________Hospital, Municipality/City/Province

Prepared by: CORA LE O. VITERBO  Printed Name with Signature of Student : CORA LE O. VITERBO______________  ___________ 

Date Performedand

Time Started

Patient’s INITIALS(only

)Immediate NewbornCord Care

PERFORMED

Indicate whereperformed e.g.

Nurse On Duty(Name and Signature) (If 

Midwife on Duty,Signature Not Required)

SUPERVISED BY Clinical Instructor

Name and Signature  Case

Number(not

applicable for 

 July 19, 20111:04 p.m.

Baby boy A.#13525 Neonatal Intensive Care Unit Jesucristina Picardal R.N. Racquel V. Magsipoc R.N., M

ODC Form 1cCORD CARE FORM

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Noted by:  ___________ LOTIS MELINDA V. BERNARTE R.N. MAN 

______________  Approved by: WENDYACEBEDO R.N. MAN_______________ 

(Print Name and Signature) (Pr

Signature) Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________  Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014

Date document is signed: _______________ Time: ______________________ __ Date document is signed: __________ Time: __________________________

Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing

 __________________

 JOSE RIZAL UNIVERSITY 80 Shaw Boulevard, Mandaluyong City

Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu

www.jru.edu.ph

ACTUAL DELIVERY in  ______________Mandaluyong City Medical Center, Mandaluyong City_________________________Hospital, Municipality/City/Province

Prepared by: CORA LE O. VITERBO  Printed Name with Signature of Student : CORA LE O. VITERBO______________  ___________ 

(

STRICTLY NO

DELEGATES)

ODC Form 1AACTUAL DELIVERY 

FORM

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Noted by:  ___________ LOTIS MELINDA V. BERNARTE R.N. MAN 

______________  Approved by: WENDY R. AR.N. MAN 

_______________

(Print Name and Signature) (PrSignature)

Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________  Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014

 ______________ 

Date document is signed: _______________ Time: ______________________ __ Date document is signed:

  __________ Time:

 __________________________

Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing

 __________________

 JOSE RIZAL UNIVERSITY 

80 Shaw Boulevard, Mandaluyong City

Date Performedand

Time Started

Patient’s INITIALS(only

)  

PROCEDUREPERFORMED

D.R. Nurse On Duty(Name and Signature) (If 

Midwife on Duty,Signature Not Required)

SUPERVISED BY Clinical Instructor

Name and Signature  CaseNumber

(notapplicable for 

April 28, 20116:28 p.m.

I.Q.545550 Normal Spontaneous Delivery

Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

April 28, 20118:42 p.m.

 Y.R.545553 Normal Spontaneous Delivery Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

(STRICTLY NO

DELEGATES)

ODC Form 1BASSISTED

DELIVERY FORM

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Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu

www.jru.edu.ph

ACTUAL DELIVERY in  ______________Mandaluyong City Medical Center, Mandaluyong City_________________________Hospital, Municipality/City/Province

Prepared by: COR A LE O. VITERBO

  Printed Name with Signature of Student : CORA LE O. VITERBO ___________ 

Noted by: 

___________ LOTIS MELINDA V. BERNARTE R.N. MAN 

______________  Approved by: WENDY R. AR.N. MAN_______________

(Print Name and Signature) (PrSignature)

Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________  Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014

 ______________ 

Date document is signed: _______________ Time: ______________________ __ Date document is signed:

  __________ Time:

 __________________________

Date Performedand

Time Started

Patient’s INITIALS(only

)  

PROCEDUREPERFORMED

D.R. Nurse On Duty(Name and Signature) (If 

Midwife on Duty,Signature Not Required)

SUPERVISED BY Clinical Instructor

Name and Signature  CaseNumber

(notapplicable for 

 January 21, 20124:41 p.m.

R.O.552786 Normal Spontaneous Delivery Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

 January 22, 20122:35 p.m.

N.B.552807 Normal Spontaneous Delivery Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

 January 24, 201210: 43 a.m.

F.V.552842 Normal Spontaneous Delivery Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

 January 24, 201211:10 a.m.

I.L.552848 Normal Spontaneous Delivery Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

 January 24, 20123:04 p.m.

M.D.552851 Normal Spontaneous Delivery Charmaine Albaña R.N. Teresita J. Dimayacyac R.N., M

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Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing  __________________

 JOSE RIZAL UNIVERSITY 80 Shaw Boulevard, Mandaluyong City

Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu

www.jru.edu.ph

IMMEDIATE NEWBORN CORD CARE in  __ Mandaluyong City Medical Center, Mandaluyong City____Hospital, Municipality/City/Province

Prepared by: CORA LE O. VITERBO  Printed Name with Signature of Student : CORA LE O. VITERBO ___________ 

Date Performedand

Time Started

Patient’s INITIALS(only)

Immediate NewbornCord Care

PERFORMEDIndicate where

performed e.g.

Nurse On Duty(Name and Signature) (If 

Midwife on Duty,Signature Not Required)

SUPERVISED BY Clinical Instructor

Name and Signature  CaseNumber

(not

applicable for  January 23, 2012

7:55 p.m.

Baby Boy A.552863 Neonatal Intensive Care Unit  Thelma Bendian R.N. Menchie T. Hi lay R.N., M.A.N

(STRICTLY NO

DELEGATES)

ODC Form 1CCORD CARE FORM

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Noted by:  ___________ LOTIS MELINDA V. BERNARTE R.N. MAN ______________  Approved by: WENDY

ACEBEDO R.N. MAN_______________  (Print Name and Signature) (PrSignature)

Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________  Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014

Date document is signed: _______________ Time: ______________________ __ Date document is signed:   __________ Time: __________________________

Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing  __________________

 JOSE RIZAL UNIVERSITY 80 Shaw Boulevard, Mandaluyong City

Tel no: 531-8031/Fax: 532-1418/ jru@jru.edu

Date Performedand

Time Started

Patient’s INITIALS(only)   SURGICAL

PROCEDUREPERFORM

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

SUPERVISED BY Clinical Instructor

Name and SignatureCase Number

 July 5, 201112:30 a.m.

M.C.022789 Suturing

 Jefferson Flor R.N. Gabriela E. Castillon R.N., M.A

 July 4, 2011

11:45 p.m.

E.T.

092977

Suturing

 Jefferson Flor R.N. Gabriela E. Castillon R.N., M.A

(STRICTLY NO

DELEGATES)

ODC Form 2BO.R MINOR

FORM

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SURGICAL SCRUB in  ______________Navotas Emergency and Lying-In Clinic, Navotas City_________________________Hospital, Municipality/City/Province

Prepared by: CORA LE O. VITERBO  Printed Name with Signature of Student : CORA LE O. VITERBO ___________ 

Noted by:  ___________ LOTIS MELINDA V. BERNARTE R.N. MAN ______________  Approved by: WENDYACEBEDO R.N. MAN_______________ 

(Print Name and Signature) (PrSignature)

Clinical Coordinator, PRC I.D No. 0183313___ Valid Until July 24, 2014________  Dean, PRC I.D. No. 0191572 Valid Until June 11, 2014

Date document is signed: _______________ Time: ______________________ __ Date document is signed:   __________ Time: __________________________

Please specify Highest Nursing Degree Earned: Masters of Arts in Nursing________ ___ Specify Highest Nursing Degree Earned: Masters of Arts in Nursing  __________________

Date Performedand

Time Started

Patient’s INITIALS(only)   SURGICAL

PROCEDUREPERFORM

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

SUPERVISED BY Clinical Instructor

Name and SignatureCase Number

 June 25, 20119:15 a.m.

R.C.2011-1542 Onchiectomy Arlenedale A. Canto R.N.,

M.A.N. Eleonor C. Tangkeko R.N., M.

(STRICTLY NO

DELEGATES)

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