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MSHC Ordr PRC Format

This document contains forms from Mindanao Sanitarium & Hospital College in the Philippines. It provides information about the school such as its accreditation status and contact information. It then includes several forms that nursing students must complete when performing procedures like deliveries, newborn care, surgical scrubs, and circulating in the operating room. The forms require documentation of key details like the patient's initials, date, time, procedure performed, and supervisor's approval.

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Cristina L. Jayson
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© Attribution Non-Commercial (BY-NC)
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42 views

MSHC Ordr PRC Format

This document contains forms from Mindanao Sanitarium & Hospital College in the Philippines. It provides information about the school such as its accreditation status and contact information. It then includes several forms that nursing students must complete when performing procedures like deliveries, newborn care, surgical scrubs, and circulating in the operating room. The forms require documentation of key details like the patient's initials, date, time, procedure performed, and supervisor's approval.

Uploaded by

Cristina L. Jayson
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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MindanaoSanitarium&HospitalCollege

Barangay San Miguel, Iligan City 9200


Phone No.(063) 221-9219, Fax No. (063) 223-2114, [email protected]
Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated
Accreditation Level: Level II, April 29, 2011-April 2014
Accredited By: Adventist Accrediting Association
Accreditation Level: Level II, October 4, 2010-December 31, 2012

D.R. Form
ACTUAL DELIVERY FORM

ACTUAL DELIVERY in:


Hospital/Home/Lying-in, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student:
Date Performed
and
Time Started

Patients INITIAL Only


Case Number
(Not Applicable for Birthing/Lying-in
Clinics/Homes)

PROCEDURE PERFORMED

D.R. Nurse on Duty


(Name and Signature)
(If Midwife on Duty, Signature Not
Required)

Noted by:

Approved by:

(Print Name and Signature)


Clinical Coordinator, PRC I.D. No.:
Valid Until:
Date document is signed:
Time:
Please specify Highest Nursing Degree Earned:

(Print Name and Signature)


Dean, PRC I.D. No.:
Valid Until:
Date document is signed:
Time:
Please specify Highest Nursing Degree Earned:

SUPERVISED BY:
Clinical Instructor
Name and Signature

MindanaoSanitarium&HospitalCollege

ICNB Form
IMMEDIATE CARE OF THE
NEWBORN FORM

Barangay San Miguel, Iligan City 9200


Phone No.(063) 221-9219, Fax No. (063) 223-2114, [email protected]
Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated
Accreditation Level: Level II, April 29, 2011-April 2014
Accredited By: Adventist Accrediting Association
Accreditation Level: Level II, October 4, 2010-December 31, 2012
IMMEDIATE NEWBORN CORD CARE in:
Hospital/Home/Lying-in, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student:
Date Performed
And
Time Started

Patients INITIAL Only


Case Number
(Not Applicable for Birthing/Lying-in
Clinics/Homes)

Immediate Newborn Cord Care


PERFORMED
Indicate where performed e.g. D.R., Nursery,
NICU, or Home

Nurse on Duty
(Name and Signature)
(If Midwife on Duty, Signature Not
Required)

Noted by:

Approved by:

(Print Name and Signature)


Clinical Coordinator, PRC I.D. No.:
Valid Until:
Date document is signed:
Time: ______________________
Please specify Highest Nursing Degree Earned:

(Print Name and Signature)


Dean, PRC I.D. No.:
Valid Until:
Date document is signed:
Time:
Please specify Highest Nursing Degree Earned:

SUPERVISED BY:
Clinical Instructor
Name and Signature

MindanaoSanitarium&HospitalCollege
Barangay San Miguel, Iligan City 9200
Phone No.(063) 221-9219, Fax No. (063) 223-2114, [email protected]
Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated
Accreditation Level: Level II, April 29, 2011-April 2014
Accredited By: Adventist Accrediting Association
Accreditation Level: Level II, October 4, 2010-December 31, 2012

O.R.Form 1A
O.R.SCRUB FORM
MAJOR

SURGICAL SCRUB in:


Hospital/Home/Lying-in, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student:
Date Performed
and
Time Started

Patients INITIAL Only


Case Number

SURGICAL PROCEDURE PERFORMED

Noted by:

Approved by:

(Print Name and Signature)


Clinical Coordinator, PRC I.D. No.:
Valid Until:

Dean, PRC I.D. No.:

O.R. Nurse on Duty


(Name and Signature)

(Print Name and Signature)


Valid Until:

SUPERVISED BY:
Clinical Instructor
Name and Signature

Date document is signed:


Please specify Highest Nursing Degree Earned:

Time: ______________________

Date document is signed:


Time:
Please specify Highest Nursing Degree Earned:

MindanaoSanitarium&HospitalCollege

O.R. Form 1B
O.R. CIRCULATING FORM

Barangay San Miguel, Iligan City 9200


Phone No.(063) 221-9219, Fax No. (063) 223-2114, [email protected]
Accredited By: Association of Christian Schools, Colleges, & Universities, Accrediting Agency, Incorporated
Accreditation Level: Level II, April 29, 2011-April 2014
Accredited By: Adventist Accrediting Association
Accreditation Level: Level II, October 4, 2010-December 31, 2012
CIRCULATING NURSE in:
Hospital/Home/Lying-in, Municipality/City/Province
Prepared by:
Printed Name and Signature of Student:
Date Performed
and
Time Started

Patients INITIAL Only


Case Number

SURGICAL PROCEDURE PERFORMED

Noted by:

Approved by:

(Print Name and Signature)


Clinical Coordinator, PRC I.D. No.:
Valid Until:
Date document is signed:
Time: ______________________

Dean, PRC I.D. No.:


Date document is signed:

O.R. Nurse on Duty


(Name and Signature)

(Print Name and Signature)


Valid Until:
Time:

SUPERVISED BY:
Clinical Instructor
Name and Signature

Please specify Highest Nursing Degree Earned:

Please specify Highest Nursing Degree Earned:

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