UNIVERSITY OF PANGASINAN COLLEGE OF NURSING

Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: RUIZ, Nonaliza Dumantay First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program: June2007 2011

University Seal

II.
No. DATE of OPERATION TIME of OPERATI ON STARTED -ENDED 11:15 AM 11:30 AM PATIENTS INITIALS CASE NO. R.B.B Boil at Left Foot 53291 DIAGNOSIS

MINOR OPERATION
TYPE of ANESTHESIA NAME of SURGEON NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

OPERATION PERFORMED

January 12, 2011

Boil at Left Foot Icision and Drinage

None

Dr. Saniata Fernanadez

CDVMH Jommel F. Versola, RN

LEGEND: CDVMH = Col. Domingo A. Valdez Memorial Hospital ( Primary )

Concurred by: NIDA G. QUILON CDVMH, Chief Nurse PRC I.D. No.: 0119780 Valid Until: March 17, 2011 PNA No.: 013609 Valid Until: Lifetime Member ANSAP No.: 090046 Valid Until: December 31, 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M A.N

Prepared by:

NODBWDKFDFWUF D. RUIZ NONALIZA

Student

Supervised by: Date signed: Degree: PRC I.D. No.: PNA No.:

JOMMEL F. VERSOLA
Clinical Instructor B.S.N R.N 0400856 040447 Valid Until: May 19, 2012 Valid Until: October 31, 2011

Noted by:

ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2014 PNA No.: 013926 Valid Until: October 31, 2012 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.A.N

Approved by:

MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 09, 2013 PNA No.: 2011- 040351 Valid Until: October 31, 2011 ADPCN No.: 19482 Valid Until: May 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.A.N

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING

Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: ROSALES, Johnedel Mendoza First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program: June2005 2011

University Seal

I. MINOR OPERATIONS
No. DATE of OPERATION TIME of OPERATI ON STARTED -ENDED 11:20 AM 11:48 AM 11:10 AM 11:50 AM 02:50 PM 03:01 PM PATIENTS INITIALS CASE NO. T.J.P 108481 J.C.P 108489 I.R.C 108475 Mass, Left Gluteal Area 4x4 centimeter To Consider Lipoma versus Sebaceous Cyst Abscess Left Forearm Breast Mass Left To Consider Abscess Formation DIAGNOSIS OPERATION PERFORMED TYPE of ANESTHESIA NAME of SURGEON NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

October 26, 2010

Excision Incision And Drainage Aspiration Biopsy

Local anesthesia

Dr. Leo C. Bautista

R1MC Jefferson P. Peduca, RN, RM

2 3

October 26, 2010 October 26, 2010

Local anesthesia Local anesthesia

Dr. Leo C. Bautista Dr. Leo C. Bautista

R1MC R1MC

Jefferson P. Peduca, RN, RM Jefferson P. Peduca, RN, RM

LEGEND:
Concurred by:

Prepared by: JOHNEDEL M. ROSALES Student

R1MC, Chief Nurse PRC I.D. No.: 46196 Valid Until: February 03, 2011 PNA No.: 2401 Valid Until: Lifetime Member ANSAP No.: 0106 Valid Until: Lifetime Member Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.S.N

Supervised by: Date signed: Degree: PRC I.D. No.: PNA No.:

JEFFERSON P. PEDUCA Clinical Instructor July 29, 2010 BSN RN, RM 0379703 Valid Until: October 07, 2011 01379 Valid Until: October 31, 2010

Noted by:

PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 013926 Valid Until: October 31, 2010 Date document is signed: 2011 - 040412 Time: Please specify Highest Nursing Degree Earned: M.A.N

Approved by:

PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 09, 2013 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: 19482 Valid Until: May 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.A.N

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING

Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

II. ACTUAL DELIVERIES

No. 1 2 3 4 5 LEGEND: Prepared by: Student
Concurred by: Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: Date document is signed: Please specify Highest Nursing Degree Earned:

DIAGNOSIS

MOTHERS INITIALS CASE NO.

AGE

DATE of DELIVERY

TIME of DELIVERY

GENDER of BABY

TYPE of DELIVERY

NAME of HOSPITAL

Name & Signature of Qualified Clinical Instructor

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

Noted by:

PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please specify Highest Nursing Degree Earned:

Approved by:

PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 9, 2010 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned:

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING

Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program:

University Seal

III.
No. 1 2 3 4 5 LEGEND: DIAGNOSIS MOTHERS INITIALS CASE NO. AGE DATE of DELIVERY

ASSISTED DELIVERIES
TIME of DELIVERY GENDER of BABY TYPE of DELIVERY NAME of HOSPITAL
Name & Signature of Qualified Clinical Instructor

Prepared by: Student

Concurred by: Chief Nurse PRC I.D. No.: Valid Until: PNA No.: Valid Until: Date document is signed: Please specify Highest Nursing Degree Earned:

Time:

Supervised by: Clinical Instructor Date signed: Degree: PRC I.D. No.: PNA No.: Valid Until: Valid Until:

Noted by:

PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 029069 Valid Until: October 31, 2010 Date document is signed: Time: Please specify Highest Nursing Degree Earned:

Approved by:

UNIVERSITY OF PANGASINAN COLLEGE OF NURSING

PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 9, 2010 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: Valid Until: Date document is signed: Time: Please specify Highest Nursing Degree Earned:

Arellano St., Dagupan City Phone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph (Level I PACUCOA; Year Granted: March 05, 2007) (Date School / Program was recognized: May 19, 1976; Number: 44; Year: 1976) NAME OF STUDENT: ROSALES, Johnedel Mendoza First course (if any): School graduated from: Year: Year of admission in the BSN Program: Year graduated from BSN Program: June2005 2011

University Seal

IV.
BABYS TIME OF INITIALS No. DATE PERFORMED DELIVERY CASE NO. B.G.B 1 June 10,2010 08:19 AM 149826 B.B.L 2 June 16,2010 07:22 AM 150204 B.G.T 3 June 17,2010 06:17 PM 150258 B.B.C 4 June 17,2010 08:38 AM 150268 B.G.A 5 June 18,2010 10:20 AM 150352 LEGEND:TPH = Tarlac Provincial Hospital (Tertiary)

IMMEDIATE NEWBORN CORD CARE

MOTHERS INITIALS I.D.B R.N.L M.V.S.T J.M.C M.L.R.A AGE 24 25 39 24 17 NAME of HOSPITAL TPH TPH TPH TPH TPH
Name & Signature of Qualified Clinical Instructor

GENDER of BABY Female Male Female Male Female

Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN Miss Gee Lou C. Tibayan, RN

Concurred by:

Prepared by: JOHNEDEL M. ROSALES Student

TPH, Chief Nurse PRC I.D. No.: 46196 Valid Until: February 03, 2011 PNA No.: 2401 Valid Until: Lifetime Member ANSAP No.: 0106 Valid Until: Lifetime Member Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.S.N

Supervised by: Date signed: Degree: PRC I.D. No.: PNA No.:

GEE LOU C. TIBAYAN Clinical Instructor BSN - RN 0352751 Valid Until: September 17, 2010 013913 Valid Until: October 31, 2010

Noted by:

PROF. ZENAIDA M. BAUTISTA Clinical Coordinator PRC I.D. No.: 0133422 Valid Until: July 27, 2011 PNA No.: 013926 Valid Until: October 31, 2010 Date document is signed: 2011 - 040412 Time: Please specify Highest Nursing Degree Earned: M.A.N

Approved by:

PROF. MARIA TERESA R. FAJARDO Dean PRC I.D. No.: 0160104 Valid Until: September 09, 2013 PNA No.: 013739 Valid Until: October 31, 2010 ADPCN No.: 19482 Valid Until: May 2011 Date document is signed: Time: Please specify Highest Nursing Degree Earned: M.A.N