LYCEUM-NORTHWESTERN UNIVERSITY
Tapuac District, Dagupan City
(075) 516-2429/ Fax No. (63) (75) 516-2434
Email : info@[Link]/[Link]
SURGICAL SCRUB in BLESSED FAMILY DOCTORS GENERAL HOSPITAL/SAN CARLOS CITY/PANGASINAN O.R. Form 1A
Hospital, Municipality/City/Province O.R. SCRUB FORM
Prepared by: Major
(Printed Name with Signature of Student: PILAPIL, RHONA RHEZ
Date Performed Patient’s INITIALS SURGICAL PROCEDURE SUPERVISED BY
and (only) PERFORMED O.R. Nurse On Duty
Clinical Instructor
Time Started Case Number (Name and Signature)
(Name and Signature)
OCTOBER 21.2022 D.D.F. TRANSURETHRAL RESECTION OF THE PROSTATE RONALD G. CRUZ, RN, MAN
10:30 AM 22-04212 (TURP)
JUNE 20, 2023 M.A.C.T. EMERGENCY LOW TRANSVERSE CESAREAN SECTION RONALD G. CRUZ, RN, MAN
10:30 AM 23-00373
JUNE 21, 2023 D.S.C. OPEN REDUCTION AND INTERNAL FIXATION – LEFT RONALD G. CRUZ, RN, MAN
9:00 AM 23-00394 FEMUR
Noted by: HILDA V. CRUZ Approved by: JUDITH M. MANUE Clinical Coordinator
College Dean
PRC I.D. No. _ 0321370 _ Valid Until : October 29, 2024 PRC I.D. No. 0104865_ Valid Until : August 01, 2025
Date document is signed : ______________ Time : ______________________ Date document is signed : _________ Time : ____________________
Highest Nursing Degree Earned : R.N.,M.A.N Highest Nursing Degree Earned : R.N.,M.A.N,Ed.D.
LYCEUM-NORTHWESTERN UNIVERSITY
Tapuac District, Dagupan City
(075) 516-2429/ Fax No. (63) (75) 516-2434
Email : info@[Link]/[Link]
SURGICAL SCRUB in BLESSED FAMILY DOCTORS GENERAL HOSPITAL/SAN CARLOS CITY/PANGASINAN
O.R. Form 1B
Hospital, Municipality/City/Province
O.R. CIRCULATING
Prepared by:
FORM
(Printed Name with Signature of Student: PILAPIL , RHONA RHEZ
Date Performed Patient’s INITIALS (only) O.R. Nurse On Duty SUPERVISED BY
and SURGICAL PROCEDURE (Name and Signature)
Case Number Clinical Instructor
Time Started PERFORMED (Name and Signature)
JUNE 21, 2023 J.A.C.
9:00 AM 23-00399 OPEN CHOLECYSTECTOMY RONALD G. CRUZ, RN, MAN
HOCTOBER 23, [Link].
2023 13-00386 TOTAL THYROIDECTOMY RONALD G. CRUZ, RN, MAN
2:00 PM
Noted by: HILDA V. CRUZ Approved by: JUDITH M. MANUEL
Clinical Coordinator College Dean
PRC I.D. No. _ 0321370 _ Valid Until : October 29, 2024 PRC I.D. No. 0104865_ Valid Until : August 01, 2025
Date document is signed : ______________ Time : ______________________ Date document is signed : _________ Time : ____________________
Highest Nursing Degree Earned : R.N.,M.A.N Highest Nursing Degree Earned : R.N.,M.A.N,Ed.D.
