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Surgical Scrub Records by John Dale Agasan

The document contains various surgical scrub and delivery forms prepared by student Johndale R. Agasan at the Polytechnic College of Davao del Sur, detailing procedures performed at different hospitals. It includes information on surgical procedures such as cesarean sections and hysterectomies, as well as actual deliveries and immediate newborn care. Each entry is noted and approved by clinical coordinators and instructors, including their credentials and validity dates.

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mariatheressacanada70
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
58 views11 pages

Surgical Scrub Records by John Dale Agasan

The document contains various surgical scrub and delivery forms prepared by student Johndale R. Agasan at the Polytechnic College of Davao del Sur, detailing procedures performed at different hospitals. It includes information on surgical procedures such as cesarean sections and hysterectomies, as well as actual deliveries and immediate newborn care. Each entry is noted and approved by clinical coordinators and instructors, including their credentials and validity dates.

Uploaded by

mariatheressacanada70
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

O.R.

Form 1A
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. O.R. SCRUB FORM
Major
MacArthur Highway, Barangay Kiagot, Digos City
Tel No:(082) 237-4827, E-Mail Address: digospcds@[Link],

SURGICAL SCRUB in DIGOS DOCTOR’S HOSPITAL, INC. , DIGOS CITY, DAVAO DEL SUR
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIALS Only SURGICAL PROCEDURE O.R. Nurse On Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
PERFORMED Name & Signature
LOWER SEGMENT
09-07-2023 D.R.C CESAREAN SECTION II
8:36 AM
20300

A.R.J OPEN REDUCTION


09-16-2023
INTERNAL FIXATION
10:53 AM 1999 PLATING PELVIS

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. O.R. Form 1A
MacArthur Highway, Barangay Kiagot, Digos City O.R. SCRUB FORM
Tel No:(082) 237-4827, E-Mail Address: digospcds@[Link], Major

SURGICAL SCRUB in MEDICAL CENTER OF DIGOS COOPERATIVE, DIGOS CITY, DAVAO DEL SUR
Hospital, Municipality/City/Province
Prepared by:
Printed Name with Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIALS Only SURGICAL PROCEDURE O.R. Nurse On Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
PERFORMED Name & Signature
TOTAL ABDOMINAL
11-17-2023 P.G.B HYSTERECTOMY BILATERAL
11:16 AM SALPINGO-OOPHORECTOMY
14070

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT
Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. O.R. Form 1B
MacArthur Highway, Barangay Kiagot, Digos City O.R. CIRCULATING
Tel No:(082) 237-4827, E-Mail Address: digospcds@[Link], FORM

SURGICAL SCRUB in MEDICAL CENTER OF DIGOS COOPERATIVE, DIGOS CITY, DAVAO DEL SUR
Hospital, Municipality/City/Province
Prepared by:
Name and Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIALS Only SURGICAL PROCEDURE O.R. Nurse On Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
PERFORMED Name & Signature

11-24-2023 M.G.S OPEN REDUCTION


9:57 AM INTRAMEDULLARY NAILING RIGHT
14397

02-07-2024 C.I.P TOTAL ABDOMINAL


5:52 PM HYSTERECTOMY BILATERAL
1714
SALPINGO-OOPHORECTOMY

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
2026 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: Date Document signed Time:
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. O.R. Form 1B
MacArthur Highway, Barangay Kiagot, Digos City O.R. CIRCULATING
Tel No:(082) 237-4827, E-Mail Address: digospcds@[Link], FORM

SURGICAL SCRUB in DIGOS DOCTOR’S HOSPITAL, INC. , DIGOS CITY, DAVAO DEL SUR
Hospital, Municipality/City/Province
Prepared by:
Name and Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIALS Only SURGICAL PROCEDURE O.R. Nurse On Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
PERFORMED Name & Signature
IMMEDIATE CESAREAN SECTION
09-09-2023 J.R.T WITH BILATERAL TUBAL
9:52 PM LIGATION
203007

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
2026 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: Date Document signed Time:
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. D.R. Form
MacArthur Highway, Barangay Kiagot, Digos City ACTUAL DELIVERY
Tel No:(082) 237- 4827, E-Mail Address: digospcds@[Link], FORM

ACTUAL DELIVERY in SOUTHERN PHILIPPINES MEDICAL CENTER, DAVAO CITY, PHILIPPINES


Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Name and Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIAL Only PROCEDURE PERFORMED D.R Nurse on Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
(not applicable for Birthing/ (If Midwife on Duty, Name & Signature
Lying in Clinics/Homes) Signature not Required)

07-17-2023 P.J ACTUAL DELIVERY VIA NORMAL


7:31AM 286466 SPONTANEOUS VAGINAL DELIVERY

07-17-2023 R.M.F ACTUAL DELIVERY VIA NORMAL


11:57 AM SPONTANEOUS VAGINAL DELIVERY
2524828

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT
Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. D.R. Form
MacArthur Highway, Barangay Kiagot, Digos City ASSISTED DELIVERY
Tel No:(082) 237- 4827, E-Mail Address: digospcds@[Link], FORM

ACTUAL DELIVERY ASSISTED in DAVAO DEL SUR PROVINCIAL HOSPITAL, DIGOS CITY, DAVAO DEL SUR
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Name and Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIAL Only PROCEDURE PERFORMED D.R Nurse on Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
(not applicable for Birthing/ (If Midwife on Duty, Name & Signature
Lying in Clinics/Homes) Signature not Required)
JEANETTE C.
9-16-2022 J.T.T ASSISTED DELIVERY VIA NORMAL GARNER, RM
5:49 AM 502494 SPONTANEOUS VAGINAL DELIVERY LIC. NO.0106571

JASMIN S. ANDOY, RM
01-28-2023 B.R.M ASSISTED DELIVERY VIA NORMAL LIC. NO. 0165778
6:08 AM 481487 SPONTANEOUS VAGINAL DELIVERY

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT
Page of
ICNB Form
IMMEDIATE CARE OF
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. THE NEWBORN FORM
MacArthur Highway, Barangay Kiagot, Digos City
Tel No:(082) 237-4827, E-Mail Address: digospcds@[Link],

IMMEDIATE NEWBORN CORD CARE in DAVAO DEL SUR PROVINCIAL HOSPITAL, DIGOS CITY, DAVAO DEL SUR
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Name & Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIAL Only Immediate Newborn Cord Care D.R Nurse on Duty Supervised By:
Time Started Case Number Performed (Name and Signature) Clinical Instructor
(not applicable for Birthing/ Indicate where performed e.g. D.R., Nursery, NICU, or (If Midwife on Duty, Name & Signature
Lying in Clinics/Homes) Home Signature not Required)
SUSAN A.
01-28-2023 BABY GIRL SURPORSA
01:04 AM 481476 Delivery Room
,RM
LIC. NO.0070798

JEANETTE C.
BABY BOY
02-3-2023 Delivery Room GARNER, RM
481856
11:23 PM
LIC. NO.0106571

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. D.R. Form
MacArthur Highway, Barangay Kiagot, Digos City ASSISTED DELIVERY
Tel No:(082) 237- 4827, E-Mail Address: digospcds@[Link], FORM

ACTUAL DELIVERY ASSISTED in SOUTHERN PHILIPPINES MEDICAL CENTER, DAVAO CITY, PHILIPPINES
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Name and Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIAL Only PROCEDURE PERFORMED D.R Nurse on Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
(not applicable for Birthing/ (If Midwife on Duty, Name & Signature
Lying in Clinics/Homes) Signature not Required)

7-17-2023 G.K ASSISTED DELIVERY VIA NORMAL


9:06 AM SPONTANEOUS VAGINAL DELIVERY
3536543

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

Page of
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. D.R. Form
MacArthur Highway, Barangay Kiagot, Digos City ACTUAL DELIVERY
Tel No:(082) 237- 4827, E-Mail Address: digospcds@[Link], FORM

ACTUAL DELIVERY in SOUTHERN PHILIPPINES MEDICAL CENTER, DAVAO CITY, PHILIPPINES


Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Name and Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIAL Only PROCEDURE PERFORMED D.R Nurse on Duty Supervised By:
Time Started Case Number (Name and Signature) Clinical Instructor
(not applicable for Birthing/ (If Midwife on Duty, Name & Signature
Lying in Clinics/Homes) Signature not Required)
SUSAN A.
01-28-2023 A.C ACTUAL DELIVERY VIA NORMAL SURPORSA
5:00 AM SPONTANEOUS VAGINAL DELIVERY ,RM
466993 LIC. NO.0070798

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

Page of
ICNB Form
IMMEDIATE CARE OF
POLYTECHNIC COLLEGE OF DAVAO DEL SUR, INC. THE NEWBORN FORM
MacArthur Highway, Barangay Kiagot, Digos City
Tel No:(082) 237-4827, E-Mail Address: digospcds@[Link],

IMMEDIATE NEWBORN CORD CARE in SOUTHERN PHILIPPINES MEDICAL CENTER, DAVAO CITY, PHILIPPINES
Hospital/Home/Lying-in Clinic, Municipality/City/Province
Prepared by:
Name & Signature of Student: JOHNDALE R. AGASAN

Date Performed & Patient’s INITIAL Only Immediate Newborn Cord Care D.R Nurse on Duty Supervised By:
Time Started Case Number Performed (Name and Signature) Clinical Instructor
(not applicable for Birthing/ Indicate where performed e.g. D.R., Nursery, NICU, or (If Midwife on Duty, Name & Signature
Lying in Clinics/Homes) Home Signature not Required)

07-17-2023 BABY BOY


9:58 AM 3509587 Delivery Room

Noted by: LEXTER G. GABICA, RN, LPT Approved by: MORSID K. TULAO, RN, MAN, CHA, PhDM
Clinical Coordinator, PRC I.D. No. 0541648 Valid Until: FEBRUARY 24, 2026 Dean, PRC I.D. No. 0890196 Valid Until: JANUARY 8, 2026
PNA No. M-63698 Valid Until: DECEMBER 31, 2025 PNA No. M-43317 Valid Until: DECEMBER 31, 2025_
Date Document signed Time: ADPCN No. 23889 Valid Until: DECEMBER 31, 2025_
Highest Nursing Degree Earned: BACHELOR OF SCIENCE IN NURSING Date Document signed Time:
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING_
DOCTOR OF PHILOSPHY IN MANAGEMENT

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