Templates

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General guidelines for signing of templates: 1. Mount all your case slips in long bond paper . Chronologically arranged. 2. Accomplish templates (see samples below). Take note of the following: a. 1 template per institution; if cases were all accomplish in 1 institution, you can put all cases in one template aslong as it can be accommodated in 1 page. If not then make another template. b. There are no case numbers for the following: ITR well baby, cases taken at ER,OPR,Minor OR of hospitals and community cases and medical-surgical mission cases. The college takes the responsibility of forwarding the certification to PRC that these cases do not bear any case number. Therefore, there is no need for you to get certification from the different institutions. c. For medical mission cases, the CI supervising signs both item for CI and Staff nurse. d. For cases accomplished during completion duty at slu and bmc without a CI, Mrs. Cherrylina Dalilis’ is place at the item CI and signs for that case. e. Cases are to be written in chronological order. First case to latest. 3. Proceed with the processing of signing of your templates by the CI and staff nurses. 4. Safe keep all accomplished templates.

ODC Form 1A ACTUAL DELIVERY FORM

SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ACTUAL DELIVERY in: Abra Provincial Hospital, Bangued, Abra
Hospital, Municipality, Province Prepared by: QUITALIG, ELVIS DE LA RAGA Date Performed And Time Started D.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Patient’s Initials Case Number

PROCEDURE PERFORMED

02-13-10 2:46 PM

A.B. 892490

Normal Spontaneous Delivery

Marie Jane Bernardez, RN

Estrella Leviste, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: MARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing (MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

Note:

For Home delivery:

Actual Delivery in: Lengaoan, Buguias, Benguet (Home Delivery) Community, Municipal, Province

ODC Form 1B ASSISTED DELIVERY FORM

SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

ASSISTED DELIVERY in: Ilocos Training and Regional Medical Center, City of San Fernando, La Union
Hospital, City, Province Prepared by: QUITALIG, ELVIS DE LA RAGA Date Performed And Time Started PROCEDURE PERFORMED ASSISTED DELIVERY D.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Patient’s Initials Case Number

12-12-09 11:10 PM 12-27-09 2:40 PM

A. P. 2009-0030928 G. A. 2009-0031553

Normal Spontaneous Delivery

Roni Joyce Novillero, RN

Charmaine Co, RN

Normal Spontaneous Delivery

Marjorie Navalta,RN

Blas Blasil Purganan, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: MARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

ODC Form 1C CORD CARE FORM

SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

IMMEDIATE NEWBORN CORD CARE in: Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, City Prepared by: QUITALIG, ELVIS DE LA RAGA Date Performed And Time Started Immediate Newborn Cord Care PERFORMED Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Patient’s Initials Case Number

04-28-09 9:30 PM

B.B.P. PB363215

Cord Care - Nursery

Wendy Villareal, RN

Felda Ibasitas, RN

ODC Form 2A O.R. SCRUB FORM Major

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: MARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

SURGICAL SCRUB in: Benguet General Hospital, La Trinidad, Benguet
Hospital, Municipality, Province Prepared by: QUITALIG, ELVIS DE LA RAGA Date Performed And Time Started O.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Patient’s Initials Case Number

SURGICAL PROCEDURE PERFORMED

06-09-09 4:27 PM

S.D. 241175

Emergency Low Segment Cesarean Section and Bilateral Tubal Ligation

Frederick Gabriel, RN

Genevieve Pablito, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: MARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

ODC Form 2B O.R. MINOR FORM

SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

SURGICAL SCRUB in: Baguio Medical Center, Baguio City
Hospital, City Prepared by: QUITALIG, ELVIS DE LA RAGA Date Performed And Time Started O.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Patient’s Initials Case Number

SURGICAL PROCEDURE PERFORMED

04-14-09 3:05 PM 10-21-09 10:34 AM

J.G. 11711434 M. D. 442

Cervical Biopsy and Diagnostic Dilation and Curettage

Chiara Rene Barcelo, RN

Lawrence Gayo, RN

Excision of Lipoma

Maria Olivia Daag, RN

Cherylina Dalilis, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: MARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

Note: if case was accomplished in a medical mission:pls follow the ff format for title

SURGICAL SCRUB in: Sanitary Camp Health Center, Baguio City (Medical Mission sponsored by Rotary Club of Baguio) Barangay, City, Sponsoring Agency

ODC Form 2C O.R. CIRCULATING

SAINT LOUIS UNIVERSITY
College of Nursing, Baguio City, 2600 Telephone Line: (074) 442-3043; 443-2001; 444-8246 to 48 Fax: (074) 442-4288; 442-2842, Website: http://www.slu.edu.ph/ CHED Recognition: Government Resolution #41 S. 1980 Accreditation: Philippine Accrediting Association of Schools Colleges and Universities (PAASCU) Level 2 valid up to 2010

O.R. CIRCULATING in: Baguio Medical Center Baguio City
Hospital, City Prepared by: QUITALIG, ELVIS DE LA RAGA Date Performed And Time Started O.R. Nurse On Duty Name and Signature Supervised by: Clinical Instructor Name and Signature

Patient’s Initials Case Number

SURGICAL PROCEDURE PERFORMED

06-16-09 3:35 PM

R. B. 11711440

Completion Curettage

Vannesa Canillas, RN

Lawrence Gayo, RN

Noted by: RUFINA C. ABUL Department Head LEVEL IV, SLU College of Nursing Master of Arts in Nursing (MAN) PRC I.D. No. 0176104 Valid until: 11-21-2011 PNA No. 13302 Valid until: LIFETIME Date signed: _______________ Time: ______________

Approved by: MARY GRACE C. LACANARIA Dean, SLU College of Nursing Master of Science in Nursing(MSN) Doctor of Philosophy in Education (PhD) PRC I.D. No.0126255 Valid until: 11-10-2013 PNA No: 9860 Valid until: LIFETIME ADPCN No: 275 Valid until: 12-31-2011 Date signed: __________________ Time: ______________

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