Minor or Format Template
Minor or Format Template
Minor or Format Template
College of Nursing
Corrales Ext. & Osmea Ext. Sts., Cagayan de Oro City
(CHED 070: PACUCOA Level 3, June 14, 1982 Manila)
SURGICAL SCRUB in Capitol University Medical City, Cagayan de Oro City
Hospital, City
Prepared by: KWESI GEM LANTACA YASAY Year of Admission in the BSN Program: June 2009
Printed Name and Signature of Student: KWESI GEM LANTACA YASAY Year Graduated in BSN Program: March 2014
No. Date Performed
Time
Started
Case
No.
Patients Name SURGICAL PROCEDURE PERFORMED
Supervised by
Name and Signature of C.I.
1
November 20, 2012
11:28 AM
023833
Marty N. Vicente
Removal of External Fixator and pin and application of
short leg posterior mold.
Jessele B. Janioso , R.N., M.N.
2
September 24,
2013
1:55 PM
001551
Leonila Maus
Cystoscopy, Ureteroscopy Right Basket Extraction of
Stone, Failed Double J Stenting
Jessele B. Janioso , R.N., M.N.
3
September 30,
2013
1:25 PM
030920
Janine Custodio
Incision Deep with Bearing of Bone Cortex Femur
Jessele B. Janioso , R.N., M.N.
4
October 1, 2013
1:20 PM
030945
Cristina Abanador
Lumpectomy
Jessele B. Janioso , R.N., M.N.
5
October 7, 2013
7:55 AM
022928
Evangeline Beja
Colonscopy
Jessele B. Janioso , R.N., M.N.
Approved by: Fidela B. Ansale, R.N., M.A.N.
(Print Name & Signature)
Dean, PRC I.D. No.: 0085045 Valid Until: February 7, 2016_______
Date Document is signed: ____________ Time: _______________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING__
Noted by: Honeylou A. Oponda, R.N., M.A, M.A.N.
(Print Name & Signature)
Clinical Coordinator, PRC I.D. No.: 0217896 Valid Until: January 6, 2016
Date Document is signed: __________________ Time: _________________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING__
Approved by: Fidela B. Ansale, R.N., M.A.N. ____
(Print Name & Signature)
Dean, PRC I.D. No.: 0085045 Valid Until: February 7, 2016_______
Date Document is signed: ____________ Time: _______________
Highest Nursing Degree Earned: MASTER OF ARTS IN NURSING__
ODC Form 2B
O.R. CIRCULATING FORM
ODC Form 2A
O.R. SCRUB FORM
Minor