University of Cebu

Lapu-lapu and Mandaue

A.C. Cortes Ave., Brgy. Looc, Mandaue City
COLLEGE OF NURSING

RELATED LEARNING EXPERIENCE RECORD BOOK

Name of Student : ______________________________________________

Date Entered : ______________________________________________

Date of Course Completion : ______________________________________________

IMPORTANT POINTS TO REMEMBER:

1. You are responsible for your RLE Record Book.

2. All entries will be checked for completeness and accuracy by the clinical instructors-in-charge of the
particular area/department.
3. The reliability and effectiveness of this record book depend upon the degree and/or sense of
responsibility; and the cooperation of the student and clinical instructor.
4. Should the student leave the College of Nursing, this record book should be surrendered and becomes
the property of the college.
5. All forms should be properly filled-up by the student.
6. All student is allowed to perform a procedure without the direct supervision of the clinical instructor
after satisfactory performance.

At the termination of the course, this book will attest the entire Related Learning Experience of the student.
 LEVEL II MASTER PLAN OF STUDENT'S RELATED LEARNING EXPERIENCE
AY 2019-2020

Month & Year Distribution of Time and Days Remarks

  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    
June                                                                
July                                                                
August                                                                
September                                                                
October                                                                
November                                                                
December                                                                
January                                                                
February                                                                
March                                                                
April                                                                
May                                                                

University of Cebu Medical Center St. Vincent General Hospital Visayas Community Medical Center
OPD           OPD         OPD        
DR           DR         DR        
Nursery           Nursery         Nursery        
Pedia         Pedia         Pedia        
OB/Gyne         OB/Gyne         OB/Gyne        

Eversley Childs' Sanitarium Community Health Nursing

OPD         ___________________        
DR        
Nursery         _________________        
Pedia        
OB/Gyne         _________________        
 LEVEL IV MASTER PLAN OF STUDENT'S RELATED LEARNING EXPERIENCE
AY 2021-2022

Month & Year Distribution of Time and Days Remarks

  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    
June                                                                
July                                                                
August                                                                
September                                                                
October                                                                
November                                                                
December                                                                
January                                                                
February                                                                
March                                                                
April                                                                
May                                                                

University of Cebu Medical Center St. Vincent General Hospital Visayas Community Medical Center

MED           MED         MED        

SURG           SURG         SURG        

ER           ER         ER        

ICU         ICU         ICU        

Pedia         Pedia         Pedia        

OR

OB/Gyne

Eversley Childs' Sanitarium Community Health Nursing PCI

MED                
SURG         Staff Nursing CHN
ER                
ICU         Head Nursing
Pedia         _________________        

INTERDEPARTMENTAL CLEARANCE

Number of
Date of Area of Instructor’s Date of Clearance
Institution Shift Rotation Grade Tardiness and
Assignment Assignment Signature and Remarks
Absences
 INTERDEPARTMENTAL CLEARANCE

Number of
Date of Area of Instructor’s Date of Clearance
Institution Shift Rotation Grade Tardiness and
Assignment Assignment Signature and Remarks
Absences
 INTERDEPARTMENTAL CLEARANCE

Number of
Date of Area of Instructor’s Date of Clearance
Institution Shift Rotation Grade Tardiness and
Assignment Assignment Signature and Remarks
Absences
 REPLACEMENT/ COMPLETION DUTIES

Year Agency and Assigned CI’s Signature over Printed

Date Shift Remarks
Level Area Name
 REPLACEMENT/ COMPLETION DUTIES

Year Agency and Assigned CI’s Signature over Printed

Date Shift Remarks
Level Area Name
 REPLACEMENT/ COMPLETION DUTIES

Year Agency and Assigned CI’s Signature over Printed

Date Shift Remarks
Level Area Name
 MASTER LIST OF NURSING PROCEDURES
I. INTEGRATING SKILLS
Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience
Demonstration Practiced
Date CI’s Date CI’s Date Grad CI’s Level 2 Level 3 Level 4
Signature Signature e Signature CI’s CI’s CI’s
Signature Signature Signature
A. Assessment of Vital Signs
1. Assessing temperature
Oral
Axilla
Rectum
2. Assessing pulse
Radial
Apical
Fetal Heart Rate
3. Assessing respiration
4. Assessing blood pressure
B. General Assessment Skills
1. Height measurement
Newborn
Adult
2. Weight-taking
newborn/infant
pediatric client
Adult
3. Measuring newborn’s head
circumference
4. Measuring abdominal girth
5. Interviewing
6. Testing urine for sugar
7. Head to toe physical
examination
Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience
Demonstration Practiced
Date CI’s Date CI’s Date Grade CI’s Level 2 Level 3 Level 4
Signature Signature Signature CI’s CI’s CI’s
Signature Signature Signature
C. Recording and Reporting
1. Writing nurse’s notes
2. Graphing TPR, BP
3. Transcribing doctor’s
order
4. Giving internship report
D. Infection Control: Medical
Asepsis
1. Medical Handwashing
2. Isolation technique:
Respiratory isolation
Enteric isolation
Protective or reverse
isolation
3. Collection of specimens
Urine
Stool
E. Wound care and Surgical
Asepsis
1. Surgical hand scrubbing
2. Donning sterile gown
3. Donning sterile gloves
4. Handling sterile forceps
5. Opening sterile packs
6. Initial skin preparation for
surgery
7. Assisting major surgery
8. Assisting minor surgery
9. Assisting spontaneous
 delivery
10. Handling spontaneous
delivery
Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience
Demonstration Practiced
Date CI’s Date CI’s Date Grade CI’s Level 2 Level 3 Level 4
Signature Signature Signature CI’s CI’s CI’s
Signature Signature Signature
11.
Cord dressing
12.
Eye treatment (newborn)
13.
Application of Breast binder
14.
Hot Sitz bath
15.
Perilight treatment
16.
Heat and cold therapy
Filling and applying a hot
water bag
Filling and applying an ice
cap
F. Medication administration
1. Preparation and
Administration of oral drugs
Tablet/Capsule
Suspension/Liquid
2. Preparation and
administration of parenteral
drugs
Intradermal
Subcutaneous
Intramuscular
3. Preparation and insertion of
suppositories
Vaginal
Rectal
4. Instillation of eyedrops
 5. Drug administration thru
NGT
G. Discharging a Patient from the
Hospital
1. Newborn
2. Pediatric
3. Adult
4. Care of unit after discharge
H. Post Mortem Care A. B. C. D. E. F. G. H. I. J. K. L.

II. ASSISTING PATIENT IN MEETING HIS PHYSIOLOGIC NEEDS

Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience
Demonstration Practiced
Date CI’s Date CI’s Date Grade CI’s Level 2 Level 3 Level 4
Signatur Signatur Signature CI’s CI’s CI’s
e e Signature Signature Signature
A. Personal Hygiene
1. Assisting patient in carrying out
oral hygiene
2. Giving special mouth care to
unconscious
3. Bathing and skin care
Bathing the newborn
Sponging a child
Cleansing bedbath (adult)
4. Care of the hair
Brushing/Combing the hair
Giving shampoo
5. Care of the feet (diabetic)
 6. Bedmaking
Open bed
Closed bed
Occupied bed
B. Providing a safe environment
1. Aesthetically; flower
arrangement
Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience
Demonstration Practiced
Date CI’s Date CI’s Date Grade CI’s Level 2 Level 3 Level 4
Signature Signature Signature CI’s CI’s CI’s
Signature Signature Signature
1. Dusting patient’s unit
2. Providing side rails
3. Applying restraints
C. Body alignment and positions
1. Assisting patient to a dorsal
recumbent position
2. Assisting patient to a lateral
position
3. Placing patient in a semi-
fowler’s position
4. Assisting patient to move up on
bed
D. Exercise and Ambulation
1. Providing passive exercise
2. Assisting patient to walk
E. Nutrition
1. Formula-making
2. Feeding a newborn
3. Feeding an infant/child
4. Assisting patient to eat
5. Feeding thru NGT
6. Burping a newborn
F. Elimination
1. Preparing and assisting in
catheterization
2. Removing an indwelling catheter
3. Cleansing enema
G. Oxygenation
1. Deep breathing and coughing
exercise

Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience

Demonstration Practiced
Date CI’s Date CI’s Date Grade CI’s Level 2 Level 3 Level 4
Signature Signature Signature CI’s CI’s CI’s
Signature Signature Signature
2. Steam inhalation
3. Nebulization
4. Chest-tapping
5. Pharyngeal/Tracheal suctioning
H. Fluid and Electrolyte Needs
1. Intake and Output measurement
2. Assisting in IV insertion
3. Computation of IV solution
4. Changing intravenous bottle
5. Discontinuing IV infusion
6. Assisting in blood transfusion
I. Care of the Newborn
1. Care of newborn’s cord
(subsequent days)
2. Carrying the baby
Traditional cradle
3. Shoulder hold
J. Nursing Care of
1. Patient upon admission
Pediatric
Adult
2. Post-partum patient
Immediately after delivery
3. Patient with oxygen therapy
4. Patient with parenteral therapy
(IV and/or blood transfusion)
5. Patient in traction
6. Patient in cast

Nursing Interventions Lecture - Supervised Return-demonstration Supervised Clinical Experience

Demonstration Practiced
Date CI’s Date CI’s Date Grade CI’s Level 2 Level 3 Level 4
Signature Signature Signature CI’s CI’s CI’s
Signature Signature Signature
7. Patient with indwelling catheter
8. Patient in labor
Leopold’s Maneuver
Timing of contractions
9. Patient immediately before
operation
10. Patient immediately after
operation
11. An unconscious patient
12. The terminal ill patient
K. Others (specify)
 SUGGESTED TOPICS FOR WARD CONFERENCES

Topic Date Area of Assignment Clinical Instructor Remarks

A. UNIFYING CONCEPTS
1. Physiologic and psychologic homeostasis
2. Stress and adaptation
3. Growth and development throughout the lifespan
4. Therapeutic communication
5. Response to illness
6. Basic human needs
B. NURSING PROCESS FOR COMMON HEALTH
PROBLEMS
1. Neoplasia
Nursing a person with Breast Cancer
2. Fluid and Electrolyte Imbalance
a) Dehydration
b) Fluid volume excess
c) Hyper/Hyponatremia
d) Hyper/Hypokalemia
3. Endocrine Problems
 a) Diabetes Mellitus
b) Insulin Therapy
c) Hyper/Hypothyroidism
d) Thyroidectomy
e) Addison’s disease
4. Neurological Problems
a) Assessing levels of consciousness
b) CVA
c) Head injuries
d) Meningitis
e) Epilepsy
f) Parkinsonism
g) Multiple Sclerosis
h) Myasthenia Gravis
Topic Date Area of Assignment Clinical Instructor Remarks
i) Care of the unconscious person
5. Musculoskeletal Problems
a) Fracture and dislocation
b) Osteomyelitis
c) Arthritis
d) Care of patient with cast
e) Care of patient with traction
f) Amputation and crutch walking
g) Complications of immobility
h) Range of motion exercise
6. Respiratory System
a) Pulmonary tuberculosis
b) Pneumonia
c) Bronchial asthma
d) COPD
e) Pleurisy
f) Bronchitis
g) Oxygen therapy
h) Suctioning
 i) Pertussis
j) Diphtheria
k) Close chest drainage
l) Breathing and coughing exercise
m) Thoracotomy
7. Cardiac problems
a) Hypertension
b) Myocardial Infarction
c) Congestive Heart Failure
d) Cardiac arrythmias
e) Angina pectoris
f) Digitalization
g) Arteriosclerosis heart disease
h) Measuring central venous pressure
Areas of
Topic Date Clinical Instructor Remarks
Assignment
8. Blood Disorders
a) Anemia
b) Leukemia
c) Dengue fever
d) Polycythemia vera
e) Rh incompatibility
9. Disorders of the Digestive System
a) Gastric ulcer
b) Intestinal obstruction
c) Hepatitis
d) Pancreatitis
e) Cholecystitis
f) Gastric surgery
g) Lavage/Gavage
h) Colostomy
i) GB series
j) Upper GI series
k) Abdominal paracentesis
 l) Liver cirrhosis
10. Urinary Problems
a) Pyelonephritis
b) Glomerulonephritis
c) Acute renal failure
d) Chronic renal failure
e) Urinary tract infection
f) Peritoneal dialysis
g) Hemodialysis
h) IVP
i) KUB
j) Nephrectomy
k) Renal transplant
11. EENT Disorders
a) Glaucoma
Topic Date Area of Assignment Clinical Instructor Remarks
b) Cataract
c) Otitis media
d) Tonsillitis
e) Tracheostomy care
f) Laryngectomy
g) Endotracheal intubation
12. Others (Specify)
 SUMMARY OF HANDLED DELIVERIES

No. Date Patient’s Name Age Time of Sex of Type of Attending Supervising Evaluator’s Name
Delivery Newborn Delivery Physician Instructor’s and Signature
Name and
Signature
 SUMMARY OF ASSISTED DELIVERIES

No. Date Patient’s Name Age Time of Type of Attending Physician Supervising Evaluator’s Name
Delivery Delivery Instructor’s Name and Signature
and Signature

1111

SUMMARY OF LABOR WATCHED

No. Date Patient’s Name Age Parity BOW Ruptured Attending Supervising Evaluator’s Name
Time Physician Instructor’s and Signature
Name and
Signature

SUMMARY OF CORD DRESSED

No. Date Name of Mother Age Time of Sex of Type of Attending Supervising Evaluator’s Name
Delivery Newborn Delivery Physician Instructor’s and Signature
Name and
Signature

SUMMARY OF FAMILY PLANNING MOTIVATION

Name of Client Case No. Age Parity Address Method Accepted Supervising
Instructor’s Name
and Signature
ANTEPARTUM

1.

2.

3.

4.

5.

POST PARTUM
1.

2.

3.

4.

5.

SUMMARY OF OPERATING ROOM CASES

Major Scrub Date Name of Patient Case Surgery Diagnosis Surgeon Remarks
No. Number Performed

Major Scrub Date Name of Patient Case Surgery Diagnosis Surgeon Remarks
No. Number Performed
 (Circulating
Nurse)

Minor Scrub Date Name of Patient Case Surgery Diagnosis Surgeon Remarks
No. Number Performed
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 STUDENT’S PROGRESS REPORT

Inclusive Dates Agency Clinical Instructor’s Notes on Inclusive Agency Clinical Instructor’s Notes on
and Student’s Performance Dates and Student’s Performance
Assigned Area Assigned Area
 DELIVERY ROOM CASES

Handled Delivery No. : 1

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Parity : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Anesthesia : __________________________________________________________

Attending Physician : __________________________________________________________

OB – Resident : __________________________________________________________

Time of Placental Separation : _____________________________________________

Type of Placental Separation : _____________________________________________

Type of Episiotomy : _____________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson

(Show computation of EDC, LMP and AOG at the back of this page)
 DELIVERY ROOM CASES

Handled Delivery No. : 2

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Parity : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Anesthesia : __________________________________________________________

Attending Physician : __________________________________________________________

OB – Resident : __________________________________________________________

Time of Placental Separation : _____________________________________________

Type of Placental Separation : _____________________________________________

Type of Episiotomy : _____________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson

(Show computation of EDC, LMP and AOG at the back of this page)
 DELIVERY ROOM CASES

Handled Delivery No. : 3

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Parity : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Anesthesia : __________________________________________________________

Attending Physician : __________________________________________________________

OB – Resident : __________________________________________________________

Time of Placental Separation : _____________________________________________

Type of Placental Separation : _____________________________________________

Type of Episiotomy : _____________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson

(Show computation of EDC, LMP and AOG at the back of this page)
 DELIVERY ROOM CASES

Assisted Delivery No. :

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Parity : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Anesthesia : __________________________________________________________

Attending Physician : __________________________________________________________

OB – Resident : __________________________________________________________

Time of Placental Separation : _____________________________________________

Type of Placental Separation : _____________________________________________

Type of Episiotomy : _____________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson

(Show computation of EDC, LMP and AOG at the back of this page)
 DELIVERY ROOM CASES

Assisted Delivery No. : 2

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Parity : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Anesthesia : __________________________________________________________

Attending Physician : __________________________________________________________

OB – Resident : __________________________________________________________

Time of Placental Separation : _____________________________________________

Type of Placental Separation : _____________________________________________

Type of Episiotomy : _____________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson

(Show computation of EDC, LMP and AOG at the back of this page)
 DELIVERY ROOM CASES

Assisted Delivery No. : 3

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Parity : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Anesthesia : __________________________________________________________

Attending Physician : __________________________________________________________

OB – Resident : __________________________________________________________

Time of Placental Separation : _____________________________________________

Type of Placental Separation : _____________________________________________

Type of Episiotomy : _____________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson

(Show computation of EDC, LMP and AOG at the back of this page)
 DELIVERY ROOM CASES

Cord Dressed No. :

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Vital Statistics : __________________________________________________________

Head Circumference : __________________________________________________________

Chest Circumference : ____________________ Temperature : ____________

Length : ____________________ Weight : ____________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Attending Pediatrician : __________________________________________________________

Pedia – Resident : __________________________________________________________

Type of Placental Separation : _____________________________________________

Apgar Score : __________________________________________________________

Ballard’s Score : __________________________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson
 DELIVERY ROOM CASES

Cord Dressed No. : 2

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Vital Statistics : __________________________________________________________

Head Circumference : __________________________________________________________

Chest Circumference : ____________________ Temperature : ____________

Length : ____________________ Weight : ____________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Attending Pediatrician : __________________________________________________________

Pedia – Resident : __________________________________________________________

Type of Placental Separation : _____________________________________________

Apgar Score : __________________________________________________________

Ballard’s Score : __________________________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson
 DELIVERY ROOM CASES

Cord Dressed No. : 3

Hospital Number : __________________________________________________________

Name of Hospital : __________________________________________________________

Patient’s Name : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

Civil Status : __________________________________________________________

Room Number : __________________________________________________________

Vital Statistics : __________________________________________________________

Head Circumference : __________________________________________________________

Chest Circumference : ____________________ Temperature : ____________

Length : ____________________ Weight : ____________

Date and Time of Delivery : _____________________________________________

Type of Delivery : __________________________________________________________

Gender of the Baby : __________________________________________________________

Attending Pediatrician : __________________________________________________________

Pedia – Resident : __________________________________________________________

Type of Placental Separation : _____________________________________________

Apgar Score : __________________________________________________________

Ballard’s Score : __________________________________________________________

Diagnosis : __________________________________________________________
__________________________________________________________
__________________________________________________________

____________________ ____________________ ___________________

Student’s Name Midwife on Duty Staff Nurse on Duty

____________________ ____________________ ___________________

Clinical Instructor Evaluator Level Chairperson
 ANTEPARTUM

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

OB Score : __________________________________________________________

Sex : __________________________________________________________

Religion : __________________________________________________________

Civil Status : __________________________________________________________

Husband’s Name : __________________________________________________________

Occupation of Husband : __________________________________________________________

Method Accepted : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

____________________ ____________________
Signature of Wife Signature of Husband

____________________ ___________________ _____________________

Student’s Signature Clinical Instructor Evaluator
 (Show computation of AOG and EDC)
POSTPARTUM

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Address : __________________________________________________________

OB Score : __________________________________________________________

Sex : __________________________________________________________

Religion : __________________________________________________________

Civil Status : __________________________________________________________

Husband’s Name : __________________________________________________________

Occupation of Husband : __________________________________________________________

Method Accepted : __________________________________________________________

LMP : __________________________________________________________

EDC : __________________________________________________________

AOG : __________________________________________________________

____________________ ____________________
Signature of Wife Signature of Husband

____________________ ___________________ _____________________

Student’s Signature Clinical Instructor Evaluator
 (Show computation of AOG and EDC)
OPERATING ROOM CASES
SCRUB

Major Case No. :

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
SCRUB

Major Case No. : 2

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor

____________________ ____________________
Level Chairperson Evaluator
 OPERATING ROOM CASES
SCRUB

Major Case No. : 3

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
CIRCULATING NURSE

Major Case No. :

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
CIRCULATING NURSE

Major Case No. : 2

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
CIRCULATING NURSE

Major Case No. : 3

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
SCRUB

Minor Case No. :

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
SCRUB

Minor Case No. : 2

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator
OPERATING ROOM CASES
SCRUB

Minor Case No. : 3

Name of Patient : __________________________________________________________

Age : __________________________________________________________

Civil Status : __________________________________________________________

Address : __________________________________________________________

Name of Hospital : __________________________________________________________

Room Number : __________________________________________________________

Case Number : __________________________________________________________

Pre-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Post-Operative Diagnosis: __________________________________________________________

__________________________________________________________

Operative Procedure : __________________________________________________________

Date Performed : __________________________________________________________

Time Performed : __________________________________________________________

Type of Anesthesia : __________________________________________________________

Name of Surgeon : __________________________________________________________

Anesthesiologist : __________________________________________________________

1st Assistant : __________________________________________________________

2nd Assistant : __________________________________________________________

Circulating Nurse : __________________________________________________________

Scrub Nurse : __________________________________________________________

____________________ ____________________ ___________________

Student’s Name Scrub/Circulating Nurse Clinical Instructor
____________________ ____________________
Level Chairperson Evaluator

CLINICAL INSTRUCTOR SSPECIMEN SIGNATURE

Clinical Instructor’s Name Initial Signature