sample exhibit form new curriculum

Ateneo de Zamboanga UniversityCOLLEGE OF NURSING

Zamboanga CityPrepared by: FAMI, FIRST SECOND MIDDLE Name and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga CityRecognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013Date When School Program was recognized: CHED Memorandum No.1 series of 2005First Course: Not applicable School Graduated From: Ateneo de Zamboanga University Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year: Not ApplicableYear Graduated (BSN Program): March 2011

___________________________NAME OF STUDENT

MAJOR OPERATION

No. Date of Operation

Case No. Name of Patient Diagnosis Operation Performed

Anesthesia Name of Surgeon

Name of Hospital

Name and Signature of Scrub Nurse

Name and Signature of Qualified CI

Noted by: Concurred by: Flor P. San Luis, RN, MN Evelyn Tindick-Monsanto, R.N., MEd., M.N.Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Chief Nurse, Zamboanga City Medical CenterHighest Nursing Degree Earned Bachelor of Science in Nursing Highest Nursing Degree Earned Bachelor of Science in Nursing

Master in Nursing Master in EducationMaster in Nursing

Date signed: Date signed: PRC I.D. No. 0062360 Valid Until : January 29, 2011 PRC I.D. No. 0063627 Valid until: December 12, 2012PNA No. 017407 Valid Until : November 12, 2010 PNA No. 2927 Valid until: Life MemberANSAP I.D. No. 006547 Valid Until: January 3, 2012 ANSAP No. 0381 Valid until: Life Member

Approved by:

Maria Lorna Bello-Paber, R.N., M.A.N.

Dean, Ateneo de Zamboanga University, College of NursingHighest Nursing Degree Earned Bachelor of Science in Nursing

Master of Arts in Nursing Date signed: PRC No. 0059150 Valid Until : September 15, 2010PNA No. 6141 Valid Until : Lifetime MemberADPCN No. 0655 Valid Until : December 31, 2010


La Purisima Street, Zamboanga CityRecognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013

CHED Memorandum No.1 series of 2005Surgical Scrub in _______________________________________

Hospital, Municipality/City/Province

Prepared by:Name of Student: _ _______________________________________________________ Signature of Student: ________________________________________________________________

Date Performed and Time StartedPatient’s Name

PROCEDURE PERFORMED O.R. NURSE ON DUTY(NAME ONLY)

SUPERVISED BY:CLINICAL INSTRUCTORNAME AND SIGNATURE

Case Number




Approved by:




ODC Form 1O.R. SCRUB From

Major


Zamboanga City

Prepared by: FAMI, FIRST SECOND MIDDLEName and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga CityRecognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013Date When School Program was recognized: CHED Memorandum No.1 series of 2005First Course: Not applicable School Graduated From: Ateneo de Zamboanga University Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year: Not ApplicableYear Graduated (BSN Program): March 2011

___________________________NAME OF STUDENT

MINOR OPERATION

No. Date of Operation

Case No. Name of Patient Diagnosis Operation Performed

Anesthesia Name of Surgeon

Name of Hospital

Name and Signature of Scrub Nurse

Name and Signature of Qualified CI




Approved by:








Prepared by:Name of Student: _____________________________________________ _____________ Signature of Student: ________________________________________________________




Case Number




Approved by:




ODC Form 2O.R. SCRUB From

Minor


Zamboanga City


___________________________NAME OF STUDENT

ACTUAL DELIVERIES

No. Case No. Diagnosis Name of Patient Age Date of Delivery Time of Delivery

Gender of the Baby

Name of Hospital Type of DeliveryName & Signature of

Qualified C.I.




Approved by:








Prepared by:Name of Student: _ ___________________ _______________________________ Signature of Student: ________________________________________________________________




Case Number(not applicable for Birthing/lying-

in Clinics/Homes)




Approved by:




ODC Form 3ACTUAL DELIVERY

FORM


Zamboanga City

Prepared by: FAMI, FIRST SECOND MIDDLEName and Address of School: Ateneo de Zamboanga University, La Purisima Street, Zamboanga CityRecognition and Accreditation Level: PAASCU Accredited Level III Year Granted: May 05, 2008-2013Date When School Program was recognized: CHED Memorandum No.1 series of 2005First Course: Not applicable School Graduated From: Ateneo de Zamboanga University Year of Admission in the Bachelor of Science in Nursing Program: June 2007 Year: Not ApplicableYear Graduated (BSN Program): March 2011___________________________NAME OF STUDENT

DELIVERIES ASSISTED

No. Case No. Diagnosis Name of Patient Age Date of Delivery Time of Delivery

Gender of the Baby

Name of Hospital Type of DeliveryName & Signature of

Qualified C.I.




Approved by:








Prepared by:Name of Student: _ _______________________ _______________________________ Signature of Student: ________________________________________________________________





in Clinics/Homes)

Noted by: Concurred by: Flor P. San Luis, RN, MN Evelyn Tindick-Monsanto, R.N., MEd., M.N.Clinical Coordinator, Ateneo de Zamboanga University, College of Nursing Chief Nurse, Zamboanga City Medical CenterHighest Nursing Degree Earned Bachelor of Science in Nursing

Master in Nursing Master in Education

Master in Nursing

Date signed: Date signed: PRC I.D. No. 0062360 Valid Until : January 29, 2011PNA No. 017407 Valid Until : November 12, 2010 PNA No. 2927 Valid until: Life MemberANSAP I.D. No. 006547 Valid Until: January 3, 2012 ANSAP No. 0381 Valid until: Life Member

Approved by:




ODC Form 4D.R. ASSIST FORM


Zamboanga City


___________________________NAME OF STUDENT

CORD DRESSING

No. Case No. Date Performed Name of the Baby Gender of the Baby

Name of the Mother Age of the Mother

Name of Hospital Name & Signature of Qualified C.I.




Approved by:








Prepared by:Name of Student: _ _____________________________________________________ Signature of Student: ________________________________________________________________





in Clinics/Homes)




Approved by:




ODC Form 5D.R. CORD CARE

FORM

PRC NUMBERS:For Zamboanga City Medical Center

Noted by: Concurred by: Flor P. San Luis, RN, MN Evelyn Tindick-Monsanto, RN, Med, MNClinical Coordinator, ADZU, College of Nursing Chief Nurse, Zamboanga City Medical CenterHighest Nursing Degree Earned: Bachelor of Science in Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in Nursing Master in Education Master in Nursing

Date & time document is signed: ______________ Time: ___________ Date & time document is signed: ______________ Time: ______PRC I.D. No: 0062360 Valid until: January 29, 2011 PRC I.D. No. 0063627 Valid Until: December 12, 2009PNA No. 017407 Valid Until: December 31, 2010 PNA No. 2927 Valid Until: Life Member

ANSAP No. 0381 Valid Until: Life Member

Approved by:Maria Lorna Bello- Paber, RN, MANDean, ADZU College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in NursingDate & time document is signed: ______________ Time: ___________ PRC No.: 0069150 Valid Until: September 15, 2010PNA No. 6141 Valid Until: Lifetime MemberADPCN No. 0655 Valid Until: December 31, 2009

For Ciudad Medical Zamboanga

Noted by: Concurred by: Ma. Lourdes Concepcion-Follero, RN, MN Celita P. Calma, RN, MANClinical Coordinator, ADZU, College of Nursing Chief Nurse, Ciudad Medical ZamboangaHighest Nursing Degree Earned: Bachelor of Science in Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in Nursing Master of Arts in Nursing Date & time document is signed: ____________________ Time: _____ Date & time document is signed: ______________ Time: ______PRC I.D. No: 0115066 Valid Until: December 06, 2011 PRC I.D. No. 069666 Valid Until: March 9, 2012PNA No. 016740 Valid Until: December 31, 2009 PNA No. 18799 Valid Until: Lifetime Member

ANSAP No. 01038 Valid Until: December 31, 2009


Master in NursingDate & time document is signed: ______________ Time: ___________ PRC No.: 0069150 Valid Until: September 15, 2010PNA No. 6141 Valid Until: Lifetime Member

ADPCN No. 0655 Valid Until: December 31, 2009

For Zamboanga Doctors Hospital

Noted by: Concurred by: Ma. Lourdes Concepcion-Follero, RN, MN Maria Bella M. Tandoc, RN, MANClinical Coordinator, ADZU, College of Nursing Chief Nurse, Zamboanga Doctors HospitalHighest Nursing Degree Earned: Bachelor of Science in Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in Nursing Master of Arts in NursingDate & time document is signed: ____________________ Time: ___________ Date & time document is signed: ______________ Time: ______PRC I.D. No. 0115066 Valid until December 06, 2011 PRC I.D. No. 0041245 Valid Until::February 04, 2010PNA No. 016740 Valid Until: December 31, 2009 PNA No. 12434 Valid Until: Lifetime Member

ANSAP No. Valid Until: December 31, 2009



For Western Mindanao Medical Center

Noted by: Concurred by: Ma. Lourdes Concepcion-Follero, RN, MN Ma. Dolores B. Pacatang, RNClinical Coordinator, ADZU, College of Nursing Chief Nurse, Western Mindanao Medical CenterHighest Nursing Degree Earned: Bachelor of Science in Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in Nursing Date & time document is signed: ____________________ Time: ___________ Date & time document is signed: ______________ Time: ______PRC I.D. No. 0115066 Valid until: December 06, 2011 PRC I.D. No. 074214 Valid Until::February 2, 2011PNA No. 016740 Valid Until: December 31, 2009 PNA No. 18033 Valid Until: Lifetime Member

ANSAP No. 02629 Valid Until: December 31, 2009



For Zamboanga Puericulture Lying-In Maternity Hospital

Noted by: Concurred by: Ma. Lourdes Concepcion-Follero, RN, MN Ma. Theresa Geraldine Pioquinto, RNClinical Coordinator, ADZU, College of Nursing Chief Nurse, ZPMHHighest Nursing Degree Earned: Bachelor of Science in Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in Nursing Date & TIME document is signed: ____________________ Time: ___________ Date & TIME document is signed: ______________ Time: ______PRC I.D. No. 0115066 Valid until December 06, 2011 PRC I.D. No. 0177945 Valid Until::October 11, 2011PNA No. 016740 Valid Until: December 31, 2009 PNA No. 016531 Valid Until: December 31, 2009



For DOS

Noted by: Ma. Lourdes Concepcion-Follero, RN, MN Clinical Coordinator, ADZU, College of Nursing Highest Nursing Degree Earned: Bachelor of Science in Nursing

Master in Nursing Date & TIME document is signed: ____________________ Time: ___________ PRC I.D. No. 0115066 Valid until December 06, 2011PNA No. 016740 Valid Until: December 31, 2009

1. PAASCU Level II Re-accredited StatusYear granted: January 31, 2009 to November 20112. Chief nurse of PDMMC Salomia S. Dela Cruz PRC validity: November 20113. HOSPITAL NAMES:St. Clare's Medical CenterTaguig City HospitalJose Reyes Memorial Medical Center4. NAME OF PATIENT SHOULD BE INITIALS ONLYexample: Celeste B. Vidal- - - C.B.V. (no spaces)5. NAME OF BABY (CORD CARE)BABY + INITIALS OF MOTHERexample: Baby C.B.V.6. FIRST COURSE: Not ApplicableSchool Graduated from: Not Applicable7. CLINICAL COORDINATOR: Evelyn J. Torio

NAME: Calma, Jamie Lyn VinluanNAME & ADD OF SCHOOL: Manila Doctors College, President Diosdado Macapagal Blvd., Metropolitan Park, Pasay City*No abbreviations*Yung Doctors daw dapat may first name accdg to our president*Put an underline on top of the Scrub nurse's name*CAPITALIZE AM / PM*Gender of baby: BOY / GIRL

(for uniformity purposes)*FORMAT OF DR DX: example: Pregnancy Uterine, Full Term, 39 Weeks Age of Gestation, Cephalic in Labor, Gravida 2 Parity 1*dates: example: March 27, 2010*No anesthesia word in type of anesthesia

sample exhibit form new curriculum

Documents

la purisima street

maria lorna bello

zamboanga city recognition

mn clinical coordinator

lifetime member adpcn

date performed

lifetime member ansap

time started patients