BRENT HOSPITAL AND COLLEGES INCORPORATED
College of Nursing
EPISCOPAL DIOCESE OF SOUTHERN PHILIPPINES
P.O.BOX 33, R.T. Lim Blvd., Zamboanga City, 7000 Philippines
Tel. No. (062) 992-2859. FAX: (062) 991-2899
D.R FORM
ACTUAL DELIVERY FORM
ACTUAL DELIVERY IN:
_____________________________________________________________
Hospital/Home/ Lying-in Clinics, Municipality/ City/ Province
Prepared by:
Printed Name and Signature of Student: _______________________________
Date Performed
and
Time Started
Patient’s Initial Only
Case Number
(Not applicable for birthing/Lyingin clinic/Homes)
PROCEDURE
PERFORMED
Noted by: _________________________
Clinical Coordinator, PRC I/D/ No.: _________ Valid Until: __________
Date Signed: ______________________ Time: ___________
Highest Nursing Degree earned: __________________
D.R Nurse on Duty
Name & Signature
(If Midwife on Duty,
Signature not required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: __________________________________________
Dean, RC I.D. No.: _____________________ Valid Until: ________
Date Signed: __________________________ Time: _________
Highest Nursing Degree earned: ___________________________
BRENT HOSPITAL AND COLLEGES INCORPORATED
College of Nursing
EPISCOPAL DIOCESE OF SOUTHERN PHILIPPINES
P.O.BOX 33, R.T. Lim Blvd., Zamboanga City, 7000 Philippines
Tel. No. (062) 992-2859. FAX: (062) 991-2899
IMMEDIATE NEWBORN CORD CARE IN:
ICNB Form
Immediate Care of the
Newborn Form
__________________________________________________________
Hospital/Home/ Lying-in Clinics, Municipality/ City/ Province
Prepared by:
Printed Name and Signature of Student: _______________________________
Date Performed
and
Time Started
Patient’s Initial Only
Case Number
(Not applicable for birthing/Lying-in
clinic/Homes)
Immediate Newborn Cord Care
PERFORMED
Indicate where performed e.g., D.R.,
Nursery, NICU or, Home
Noted by: _________________________
Clinical Coordinator, PRC I/D/ No.: _________ Valid Until: __________
Date Signed: ______________________ Time: ___________
Highest Nursing Degree earned: __________________
D.R Nurse on Duty
Name & Signature
(If Midwife on Duty,
Signature not required)
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: __________________________________________
Dean, RC I.D. No.: _____________________ Valid Until: ________
Date Signed: __________________________ Time: _________
Highest Nursing Degree earned: _________________________
BRENT HOSPITAL AND COLLEGES INCORPORATED
College of Nursing
EPISCOPAL DIOCESE OF SOUTHERN PHILIPPINES
P.O.BOX 33, R.T. Lim Blvd., Zamboanga City, 7000 Philippines
Tel. No. (062) 992-2859. FAX: (062) 991-2899
SURGICAL SCRUB IN:
OR Form 1A
O.R SCRUB FORM
Major
_____________________________________________________________
Hospital/Home/ Lying-in Clinics, Municipality/ City/ Province
Prepared by:
Printed Name and Signature of Student: _______________________________
Date Performed
and
Time Started
Patient’s Initial Only
Case Number
PROCEDURE
PERFORMED
Noted by: _________________________
Clinical Coordinator, PRC I/D/ No.: _________ Valid Until: __________
Date Signed: ______________________ Time: ___________
Highest Nursing Degree earned: __________________
O.R Nurse on Duty
Name & Signature
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: __________________________________________
Dean, RC I.D. No.: _____________________ Valid Until: ________
Date Signed: __________________________ Time: _________
Highest Nursing Degree earned: ___________________________
BRENT HOSPITAL AND COLLEGES INCORPORATED
College of Nursing
EPISCOPAL DIOCESE OF SOUTHERN PHILIPPINES
P.O.BOX 33, R.T. Lim Blvd., Zamboanga City, 7000 Philippines
Tel. No. (062) 992-2859. FAX: (062) 991-2899
SURGICAL SCRUB IN:
OR Form 1B
O.R CIRCULATING FORM
_____________________________________________________________
Hospital/Home/ Lying-in Clinics, Municipality/ City/ Province
Prepared by:
Printed Name and Signature of Student: _______________________________
Date Performed
and
Time Started
Patient’s Initial Only
Case Number
PROCEDURE
PERFORMED
Noted by: _________________________
Clinical Coordinator, PRC I/D/ No.: _________ Valid Until: __________
Date Signed: ______________________ Time: ___________
Highest Nursing Degree earned: __________________
O.R Nurse on Duty
Name & Signature
SUPERVISED BY
Clinical Instructor
Name and Signature
Approved by: __________________________________________
Dean, RC I.D. No.: _____________________ Valid Until: ________
Date Signed: __________________________ Time: _________
Highest Nursing Degree earned: ___________________________