Scribd
Upload
106 views8 pages

Or and DR New Form

1) The documents are forms from the Visayas State University College of Nursing that nursing students must complete when assisting with or performing medical procedures. 2) The forms require documentation of details like the date, patient's initials, procedures performed, supervising staff and their signatures. 3) Completing and getting the forms approved signifies the students have properly documented and obtained supervision for their clinical experiences such as delivery assistance, newborn care and surgical scrubbing.

Uploaded by

Alfred Bucabuca
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 DOCX, PDF, TXT or read online on Scribd
106 views8 pages

Or and DR New Form

1) The documents are forms from the Visayas State University College of Nursing that nursing students must complete when assisting with or performing medical procedures. 2) The forms require documentation of details like the date, patient's initials, procedures performed, supervising staff and their signatures. 3) Completing and getting the forms approved signifies the students have properly documented and obtained supervision for their clinical experiences such as delivery assistance, newborn care and surgical scrubbing.

Uploaded by

Alfred Bucabuca
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 DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 8

REPUBLIC OF THE PHILIPPINES

VISAYAS STATE UNIVERSITY

College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226

ACTUAL DELIVERY in __________________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province
D.R. FORM
ACTUAL DELIVERY
FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________

Date Performed
and
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)

SUPERVISED BY
Clinical Instructor
Name and
Signature

Endorsed by: ___________________________________________________


_____________________________________________________
(Print Name and Signature)
Name and Signature)
Delivery Room Coordinator, PRC ID No. ____________ Valid Until _______
Valid Until _______

Noted by:

Date Document is signed: ____________________________


Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________

Date Document is signed: ____________________________

(Print
Clinical Coordinator, PRC ID No. __________________

Please specify Highest Nursing Degree Earned:

Approved by: ___________________________________________________


(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: ______________________________

REPUBLIC OF THE PHILIPPINES


VISAYAS STATE UNIVERSITY

College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226

ACTUAL ASSIST in __________________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province
D.R. FORM
ACTUAL ASSIST
FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________

Date Performed
and
Started

Patients INITIAL Only


Case Number

PROCEDURE
PERFORMED

D.R. Nurse on Duty


(Name and Signature)
(If Midwife on Duty,

SUPERVISED BY
Clinical Instructor

Time:

(not applicable for Birthing/


Lying-in Clinics/Homes)

Signature not Required)

Name and
Signature

Endorsed by: ___________________________________________________


_____________________________________________________
(Print Name and Signature)
Name and Signature)
Delivery Room Coordinator, PRC ID No.____________ Valid Until _______
Valid Until _______

Noted by:

Date Document is signed: ____________________________


Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________

Date Document is signed: ____________________________

(Print
Clinical Coordinator, PRC ID No. __________________

Please specify Highest Nursing Degree Earned:

Approved by: ___________________________________________________


(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: ______________________________

Time:

REPUBLIC OF THE PHILIPPINES


VISAYAS STATE UNIVERSITY

College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226

IMMEDIATE NEWBORN CORD CARE in __________________________________________________________________


Hospital/Home/Lying-in Clinic, Municipality/City/Province
ICNB FORM
IMMEDIATE CARE OF THE
NEWBORN FORM

Prepared by:
Printed Name and Signature of Student___________________________________________________

Date Performed
and
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)

D.R. Nurse on Duty


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

SUPERVISED BY
Clinical Instructor
Name and
Signature

Endorsed by: ___________________________________________________


_____________________________________________________
(Print Name and Signature)
Name and Signature)
Delivery Room Coordinator, PRC ID No.____________ Valid Until _______
Valid Until _______

Noted by:

Date Document is signed: ____________________________


Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________

Date Document is signed: ____________________________

(Print
Clinical Coordinator, PRC ID No. __________________

Please specify Highest Nursing Degree Earned:

Approved by: ___________________________________________________


(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: ______________________________

REPUBLIC OF THE PHILIPPINES


VISAYAS STATE UNIVERSITY

College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226

SURGICAL SCRUB in __________________________________________________________________


Hospital, Municipality/City/Province
O.R. FORM 1 A
O.R. SCRUB FORM
Major

Prepared by:
Printed Name and Signature of Student___________________________________________________

Date Performed
and
Started

Patients INITIAL Only


Case Number

PROCEDURE
PERFORMED

O.R. Nurse on Duty


(Name and Signature)

SUPERVISED BY
Clinical Instructor

Time:

Name and
Signature

Endorsed by: ___________________________________________________


_____________________________________________________
(Print Name and Signature)
Name and Signature)
Operating Room Coordinator, PRC ID No. ____________ Valid Until _______
Valid Until _______

Noted by:

Date Document is signed: ____________________________


Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________

Date Document is signed: ____________________________

(Print
Clinical Coordinator, PRC ID No. __________________

Please specify Highest Nursing Degree Earned:

Approved by: ___________________________________________________


(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: __________________________

Time:

REPUBLIC OF THE PHILIPPINES


VISAYAS STATE UNIVERSITY

College of Nursing
VISCA, BAYBAY CITY, LEYTE
Telefax: (053) 563-7226

SURGICAL SCRUB in __________________________________________________________________


Hospital, Municipality/City/Province
O.R. FORM 1B
O.R. CIRCULATING
FORM
Prepared by:
Printed Name and Signature of Student___________________________________________________

Date Performed
and
Started

Patients INITIAL Only


Case Number

PROCEDURE
PERFORMED

O.R. Nurse on Duty


(Name and Signature)

SUPERVISED BY
Clinical Instructor
Name and
Signature

Endorsed by: ___________________________________________________


_____________________________________________________
(Print Name and Signature)
Name and Signature)
Operating Room Coordinator, PRC ID No. ____________ Valid Until _______
Valid Until _______

Noted by:

Date Document is signed: ____________________________


Time: _____________
____________
Please specify Highest Nursing Degree Earned: ______________________________
______________________________

Date Document is signed: ____________________________

(Print
Clinical Coordinator, PRC ID No. __________________

Please specify Highest Nursing Degree Earned:

Approved by: ___________________________________________________


(Print Name and Signature)
Dean, PRC ID No. ____________ Valid Until _______
Date Document is signed: ____________________________
Time: _____________
Please specify Highest Nursing Degree Earned: __________________________

Time:

You might also like