TARLAC STATE UNIVERSITY

College of Nursing
Romulo Boulevard, San Vicente, Tarlac City 2300
Telephone: (045)493-1865 Telefax: (045)0110 website: www.tsu.edu.ph

SURGICAL SCRUB in _______________________________________________________________

Hospital, Municipality / City / Province O.R. Form 1A
Prepared by: O.R. SCRUB FORM
Printed Name with Signature of Student: __________________________________________________ Major

Date Performed Patient's INITIALS only O.R. NURSE ON DUTY SUPERVISED BY

and SURGICAL PROCEDURE PERFORMED Name and Signature Clinical Instructor
Time Started Case Number Name and Signature

O.R. Form 1B
Prepared by: O.R. CIRCULATING
Printed Name with Signature of Student: __________________________________________________ FORM

Date Performed Patient's INITIALS only O.R. NURSE ON DUTY SUPERVISED BY

and SURGICAL PROCEDURE PERFORMED Name and Signature Clinical Instructor
Time Started Case Number Name and Signature
 TARLAC STATE UNIVERSITY
College of Nursing
Romulo Boulevard, San Vicente, Tarlac City 2300
Telephone: (045)493-1865 Telefax: (045)0110 website: www.tsu.edu.ph

ACTUAL DELIVERY in _______________________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province D.R. Form
Prepared by: ACTUAL DELIVERY FORM
Printed Name with Signature of Student: __________________________________________________

Date Performed Patient's INITIALS only D.R. NURSE ON DUTY SUPERVISED BY

and Case Number (Name and Signature) Clinical Instructor
PROCEDURE PERFORMED
Time Started (not applicable for Birthing/Lying-In
Clinics/Home) (If Midwife on Duty, signature not required) Name and Signature

IMMEDIATE NEWBORN CORD CARE in _______________________________________________________________

Hospital/Home/Lying-In Clinic, Municipality/City/Province ICNB Form
Prepared by: IMMEDIATE CARE OF THE
Printed Name with Signature of Student: __________________________________________________ NEWBORN FORM

Date Performed Patient's INITIALS only Immediate Newborn Cord Care NURSE ON DUTY SUPERVISED BY
and Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-In
Indicate where performed e.g. NURSERY, NICU, or HOME
Clinics/Home) (If Midwife on Duty, signature not required) Name and Signature
 TARLAC STATE UNIVERSITY
College of Nursing
Romulo Boulevard, San Vicente, Tarlac City 2300
Telephone: (045)493-1865 Telefax: (045)0110 website: www.tsu.edu.ph

SURGICAL SCRUB in _______________________________________________________________

Hospital, Municipality / City / Province O.R. Form 1A
Prepared by: O.R. SCRUB FORM
Printed Name with Signature of Student: __________________________________________________ Major

Date Performed Patient's INITIALS only O.R. NURSE ON DUTY SUPERVISED BY

and SURGICAL PROCEDURE PERFORMED Name and Signature Clinical Instructor
Time Started Case Number Name and Signature

O.R. Form 1B
Prepared by: O.R. CIRCULATING
Printed Name with Signature of Student: __________________________________________________ FORM

Date Performed Patient's INITIALS only O.R. NURSE ON DUTY SUPERVISED BY

and SURGICAL PROCEDURE PERFORMED Name and Signature Clinical Instructor
Time Started Case Number Name and Signature
 TARLAC STATE UNIVERSITY
College of Nursing
Romulo Boulevard, San Vicente, Tarlac City 2300
Telephone: (045)493-1865 Telefax: (045)0110 website: www.tsu.edu.ph

ACTUAL DELIVERY in Tarlac Provincial Hospital

Hospital/Home/Lying-In Clinic, Municipality/City/Province D.R. Form
Prepared by: ACTUAL DELIVERY FORM
Printed Name with Signature of Studen ELOISA ANN P. VALEROSO

Date Performed Patient's INITIALS only D.R. NURSE ON DUTY SUPERVISED BY

and Case Number (Name and Signature) Clinical Instructor
PROCEDURE PERFORMED
Time Started (not applicable for Birthing/Lying-In
Clinics/Home)
(If Midwife on Duty, signature not required) Name and Signature

August 18, 2014 M.D.C

8:09am 261851 Normal Spontaneous Delivery MARJORIE D. GOROSPE ROFEL G. REUBAL, RN, MAN
PRC No.: 0704826 PRC No.: 0266821

IMMEDIATE NEWBORN CORD CARE in Tarlac Provincial Hospital

Hospital/Home/Lying-In Clinic, Municipality/City/Province ICNB Form
Prepared by: IMMEDIATE CARE OF THE
Printed Name with Signature of Studen ELOISA ANN P. VALEROSO NEWBORN FORM

Date Performed Patient's INITIALS only Immediate Newborn Cord Care NURSE ON DUTY SUPERVISED BY
and Case Number PERFORMED (Name and Signature) Clinical Instructor
Time Started (not applicable for Birthing/Lying-In
Clinics/Home)
Indicate where performed e.g. NURSERY, NICU, or HOME (If Midwife on Duty, signature not required) Name and Signature

August 18, 2014 Baby Girl V. Immediate Newborn Care

10:26am 261879 Nursery MARJORIE D. GOROSPE, RN MARY JANE N. RIGOR, RN, MSN
PRC No.: 0704826 PRC No.: 0300839