(FINAL) PRC DR Actual Assist Form 2324

D.R.
FORM
ACTUAL DELIVERY FORM
ATENEO DE ZAMBOANGA UNIVERSITY

La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED/ Accredited Level III/ Year Granted: November 2019-2024
ACTUAL DELIVERY in - _________________________________________________
Hospital, Lying-in Center, Municipality/ City/ Province
Prepared by:
Name of Student: ______________________________________ Signature of Student: ________________________________
Date Performed Patient’s Name SUPERVISED BY:

Nurse On Duty
and NATURE OF DELIVERY Name and Signature
Clinical Instructor
Time Started Name and Signature
Case Number
Noted by: Approved by:
ARACELI SEMILLA-PISON, RN, MSPH MARIA LORNA BELLO-PABER, RN, MAN

Clinical Coordinator Dean
PRC I.D. No. 0155451 Valid Until: 2026 PRC I.D. No. 0059150 Valid Until: 2025
PNA I.D. No. 21277 Valid Until: Lifetime PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2025
Date document is signed: _______________________ Time: ______________ Date document is signed: ________________________ Time: __________
Highest Degree Earned: MASTER OF SCIENCE IN PUBLIC HEALTH Highest Degree Earned: MASTER OF ARTS IN NURSING
D.R. FORM
ASSISTED DELIVERY
FORM
ATENEO DE ZAMBOANGA UNIVERSITY

La Purisima Street, Zamboanga City, Philippines
Tel. No.(63)(62)991-0871 to 76/Fax No. (63)(62) 0010870/E-mail: http://mail.adzu.edu.ph/Website: www.adzu.edu.ph
Accreditation by: PAASCU and CHED/ Accredited Level III/ Year Granted: November 2019-2024
ASSISTED DELIVERY in - _________________________________________________
Hospital, Lying-in Center, Municipality/ City/ Province
Prepared by:
Name of Student: ______________________________________ Signature of Student: ________________________________
Date Performed Patient’s Name SUPERVISED BY:

Nurse On Duty
and NATURE OF DELIVERY Name and Signature
Clinical Instructor
Time Started Name and Signature
Case Number
Noted by: Approved by:
ARACELI SEMILLA-PISON, RN, MSPH MARIA LORNA BELLO-PABER, RN, MAN

Clinical Coordinator Dean
PRC I.D. No. 0155451 Valid Until: 2026 PRC I.D. No. 0059150 Valid Until: 2025
PNA I.D. No. 21277 Valid Until: Lifetime PNA I.D. No. 6141 Valid Until: Lifetime Member
ADPCN No. 11-056 Valid Until: 2025
Date document is signed: _______________________ Time: ______________ Date document is signed: ________________________ Time: __________
Highest Degree Earned: MASTER OF SCIENCE IN PUBLIC HEALTH Highest Degree Earned: MASTER OF ARTS IN NURSING
INSTRUCTIONS FOR DR PRC
Instructions on How to fill up:
General instructions: Fill up with a pencil first, before finalizing with a pen to prevent erasures in the index card.
1. Write the full name of the hospital/agency or clinical area at the header.
2. Write your full name (First Name Middle Name Surname) and affix your signature at the opposite side under signature of student
3. Indicate the date and time started. Write it in Month Day, Year, then below the date is the time started
4. Determine the patient's name and write it in initials, and below the name, write the case number of the patient
5. Under the nature of delivery, write “Normal Spontaneous Vaginal Delivery” if the delivery is normal, and write “Vaginal Delivery” if there are
complications such as cord coil, caput, etc.
6. Write the FULL name with the title of the nurse on duty.
7. Write the FULL name with the title of your clinical instructor and let them sign above their name.
8. Once the nurse on duty affixes their signature, let your clinical instructor sign above their name.
INSTRUCTIONS FOR DR INDEX CARD (Manage & Assist)
Instructions on How to fill up:
General instructions: Fill up with a pencil first, before finalizing with a pen to prevent erasures in the index card.
1. Write your full name (First Name Middle Name Surname).

2. Write your year level and section.
3. Write the full name of the hospital/institution.
4. Write the record number.
5. Write the final diagnosis.
6. Write the FULL NAME of the patient.
7. Indicate the Age and Gender of the patient.
8. Indicate the date and time of delivery. Write it in Month Day, Year, then on the other column, writhe the time started.
9. Indicate the gender of the newborn.
10. Identify the type of delivery, either Normal Spontaneous Vaginal Delivery or Vaginal Delivery.
11. On the lower left, write the FULL name of the Staff on Duty. Then, they should affix their signature with a permanent ballpen.
12. On the lower right, write the FULL name of the clinical instructor with their titles (RN, MAN, MN, PhD). Then, they should affix their signature with a
permanent ballpen.
1. On the bottom-most part of the index card, write again the FULL name of the clinical coordinator of your batch. Then, they should affix their signature with
a permanent ballpen during the signing week.
13. Double check the information you wrote with the information placed on your PRC forms, as they will be compiled together. 1 index card comes with 1 PRC
form.

(FINAL) PRC DR Actual Assist Form 2324

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D.R.

ATENEO DE ZAMBOANGA UNIVERSITY

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

ARACELI SEMILLA-PISON, RN, MSPH MARIA LORNA BELLO-PABER, RN, MAN

ATENEO DE ZAMBOANGA UNIVERSITY

Date Performed Patient’s Name SUPERVISED BY:

Noted by: Approved by:

ARACELI SEMILLA-PISON, RN, MSPH MARIA LORNA BELLO-PABER, RN, MAN

Instructions on How to fill up:

Instructions on How to fill up:

1. Write your full name (First Name Middle Name Surname).

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