Templates
Content
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: ______________
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: ______________
