LA SALLE UNIVERSITY
VALCONCHA STREET, 7200 OZAMIZ CITY, MISAMIS OCCIDENTAL, PHILIPPINES
(88) 521-0342/registrar@lsu.edu.ph/lsu.edu.ph
ODC Form 1
O.R. SCRUB FORM
SURGICAL SCRUB in Mayor Hilarion A. Ramiro Sr. Medical Center, Ozamiz City, Misamis Occidental
Hospital, Municipality/City/Province
Prepared by:
Name of Student: JOBERT P. ROSILLOSA
Signature of Student
DATE PERFORMED AND TIME
STARTED
PATIENT’S INITIALS
November 14, 2022
12:20 P.M
C. R.
40-50-26
November 17, 2022
12:55 P.M
M. M.
40-65-54
November 17, 2022
2:50 P.M
M. G.
37-95-81
CASE NUMBER
O.R. NURSE ON DUTY
(Name Only)
SUPERVISED BY:
Clinical Instructor
Name and Signature
JAMES PAUL M. MANLOZA
BENJIEBER SILVA, MN
EXPLORATORY LAPAROTOMY,
APPENDECTOMY, LAVAGE
CLYDE NOEL T. TATOY
BENJIEBER SILVA, MN
RECTAL CANCER STAGE 3 COLOSTOMY
OBSTRUCTION
CLYDE NOEL L. TATOY
BENJIEBER SILVA, MN
PROCEDURE PERFORMED
PROCTOSIGMOIDOSCOPY
HEMORRHOIDECTOMY
Noted by: HARRIET C. JIMENEZ, RN, MN
Clinical Coordinator
Approved by: ARLENE D. APAO, RN, MN, MAN
Dean
PRC I.D No.
0622114
Valid Until: JUNE 25, 2024
PNA No.
Valid Until
Date document is signed:
Time:
Please specify Highest Nursing Degree Earned:
MN
PRC I.D No.
0205619
Valid Until
March 20, 2024
PNA No.
Valid Until
______________________
ADPCN No.
20-818__
Valid Until
May 31, 2023_________
Date document is signed:
Time
Please specify Highest Nursing Degree Earned:
MAN
LA SALLE UNIVERSITY
VALCONCHA STREET, 7200 OZAMIZ CITY, MISAMIS OCCIDENTAL, PHILIPPINES
(88) 521-0342/registrar@lsu.edu.ph/lsu.edu.ph
ODC Form 5
O.R. CIRCULATING FORM
SURGICAL CIRCULATING in Mayor Hilarion A. Ramiro Sr. Medical Center, Ozamiz City, Misamis Occidental
Hospital, Municipality/City/Province
Prepared by:
Name of Student: JOBERT P. ROSILLOSA
Signature of Student
PROCEDURE PERFORMED
O.R. NURSE ON DUTY
(Name Only)
SUPERVISED BY:
Clinical Instructor
Name and Signature
S.R
40-45-40
LAPAROSCOPIC
CHOLECYSTECTOMY
JAMES PAUL M. MANLOZA
BENJIEBER SILVA, MN
November 15, 2022
8:55 A.M
Y. C.
40-64-09
DEBRIDEMENT LEFT LEG
JOHN EDWARD V. DEGAMON
BENJIEBER SILVA, MN
November 17, 2022
9:31 A.M
C. E.
40-71-04
SUPERFICIAL PAROTIDECTOMY
SHERRIE GRACE D. DECENA MN
BENJIEBER SILVA, MN
DATE PERFORMED AND TIME
STARTED
PATIENT’S INITIALS
November 14, 2022
9:10 A.M
CASE NUMBER
Noted by: HARRIET C. JIMENEZ, RN, MN
Clinical Coordinator
Approved by: ARLENE D. APAO, RN, MN, MAN
Dean
PRC I.D No.
0622114
Valid Until: JUNE 25, 2024
PNA No.
Valid Until
Date document is signed:
Time:
Please specify Highest Nursing Degree Earned:
MN
PRC I.D No.
0205619
Valid Until
March 20, 2024
PNA No.
Valid Until
______________________
ADPCN No.
20-818__
Valid Until
May 31, 2023_________
Date document is signed:
Time
Please specify Highest Nursing Degree Earned:
MAN