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PRC - OR 2025 Revised

The document outlines the surgical scrub and circulating forms for students at La Salle University, specifically for procedures performed at Mayor Hilarion A. Ramiro Sr. Medical Center. It includes sections for student information, patient initials, procedure details, and signatures from supervising nurses and clinical instructors. Additionally, it provides validation details for nursing credentials of the clinical coordinator and dean.

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rodriguez.klienchristopher
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77 views2 pages

PRC - OR 2025 Revised

The document outlines the surgical scrub and circulating forms for students at La Salle University, specifically for procedures performed at Mayor Hilarion A. Ramiro Sr. Medical Center. It includes sections for student information, patient initials, procedure details, and signatures from supervising nurses and clinical instructors. Additionally, it provides validation details for nursing credentials of the clinical coordinator and dean.

Uploaded by

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

College of Nursing ODC Form 1


LA SALLE STREET, BRGY. AGUADA, 7200 OZAMIZ CITY, MISAMIS OCCIDENTAL, PHILIPPINES O.R. SCRUB FORM
0985-346-0730/lsu.edu.ph/[email protected]

SURGICAL SCRUB in Mayor Hilarion A. Ramiro Sr. Medical Center (MHARSMC), Ozamiz City, Misamis Occidental
Hospital, Municipality/City/Province

Prepared by:
Name of Student: ______________________________________ Signature of Student

PATIENT’S INITIALS SUPERVISED BY:


DATE PERFORMED AND TIME O.R. NURSE ON DUTY
PROCEDURE PERFORMED Clinical Instructor
STARTED (Name Only)
CASE NUMBER Name and Signature

Noted by: HARRIET C. JIMENEZ, RN, MN Approved by: ARLENE D. APAO, RN, MN, MAN
Clinical Coordinator Dean

PRC I.D No. 0622114 Valid Until: JUNE 25, 2028 PRC I.D No. 0205619 Valid Until March 20, 2027
PNA No. 99776 Valid Until: December 31, 2025 PNA No. 93869 Valid Until December 31, 2026
Date document is signed: Time: ADPCN No. 20-818__ Valid Until 2025_________________

Please specify Highest Nursing Degree Earned: MN Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN
LA SALLE UNIVERSITY ODC Form 5
College of Nursing O.R. CIRCULATING
LA SALLE STREET, BRGY. AGUADA, 7200 OZAMIZ CITY, MISAMIS OCCIDENTAL, PHILIPPINES FORM
0985-346-0730/lsu.edu.ph/[email protected]

SURGICAL CIRCULATING in Mayor Hilarion A. Ramiro Sr. Medical Center (MHARSMC), Ozamiz City, Misamis Occidental
Hospital, Municipality/City/Province
Prepared by:
Name of Student: _________________________________ Signature of Student

PATIENT’S INITIALS SUPERVISED BY:


DATE PERFORMED AND TIME O.R. NURSE ON DUTY
PROCEDURE PERFORMED Clinical Instructor
STARTED CASE NUMBER (Name Only)
Name and Signature

Noted by: HARRIET C. JIMENEZ, RN, MN Approved by: ARLENE D. APAO, RN, MN, MAN
Clinical Coordinator Dean

PRC I.D No. 0622114 Valid Until: JUNE 25, 2028 PRC I.D No. 0205619 Valid Until March 20, 2027
PNA No. 99776 Valid Until: December 31, 2025 PNA No. 93869 Valid Until December 31, 2026
Date document is signed: Time: ADPCN No. 20-818__ Valid Until 2025_________________

Please specify Highest Nursing Degree Earned: MN Date document is signed: Time
Please specify Highest Nursing Degree Earned: MAN

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