St.

Paul University Philippines

School of Health Sciences

Name of Student : ________________________________________________________________________________________________________________________________

Name & Address of School : St. Paul University Philippines, Mabini Street, Tuguegarao City_____________________________________________________________________
Accreditation Level (if any) : PAASCU LEVEL III______________________________________ Year Granted : ___________________________________________________
Date School / Program was Recognized : ______________________________________________ Number : ___________________________ Year : ______________________
First Course (if any) : ________________________________________ School Graduated From : ____________________________________ Year : ______________________
Year of Admission in the Bachelor of Science in Nursing Program : _________________________________________________________________________________________
Year Graduate (BSN Program) : _____________________________________________________________________________________________________________________

MAJOR OPERATIONS

Date of Name of Operation Type of Name of Name of Name of O.R.

No. Case No. Diagnosis Name of C.I.
Operation Patient Performed Anesthesia Surgeon Hospital Scrub Nurse
1

Prepared by : Concurred by : Noted by : Approved by :

_______________________ ____________________________________ __________________________________________ SR. TRECELLA MAY MACALAM, SPC

Signature over Printed Name Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed : ________________________ Date Signed : _______________________________ Date Signed : _______________________
Degree : ____________________________ Degree : ___________________________________ Degree : ___________________________
a) PRC No. ____________________ a.) PRC No. ____________________________ a.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
b) PNA No. ____________________ b.) PNA No. ____________________________ b.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
c) ANSAP No. _________________ c.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________
St. Paul University Philippines
School of Health Sciences
Name of Student : __________________ ______________________________________________________________________________________________________________
Name & Address of School : St. Paul University Philippines, Mabini Street, Tuguegarao City_____________________________________________________________________
Accreditation Level (if any) : PAASCU LEVEL III______________________________________ Year Granted : ___________________________________________________
Date School / Program was Recognized : ______________________________________________ Number : ___________________________ Year : ______________________
First Course (if any) : ________________________________________ School Graduated From : ____________________________________ Year : ______________________
Year of Admission in the Bachelor of Science in Nursing Program : _________________________________________________________________________________________
Year Graduate (BSN Program) : _____________________________________________________________________________________________________________________

MINOR OPERATIONS

Date of Name of Operation Type of Name of Name of Name of O.R.

No. Case No. Diagnosis Name of C.I.
Operation Patient Performed Anesthesia Surgeon Hospital Scrub Nurse
1

Prepared by : Concurred by : Noted by : Approved by :

_______________________ ____________________________________ __________________________________________ SR. TRECELLA MAY MACALAM, SPC

Signature over Printed Name Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed : ________________________ Date Signed : _______________________________ Date Signed : _______________________
Degree : ____________________________ Degree : ___________________________________ Degree : ___________________________
a) PRC No. ____________________ a.) PRC No. ____________________________ a.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
b) PNA No. ____________________ b.) PNA No. ____________________________ b.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
c) ANSAP No. _________________ c.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________

St. Paul University Philippines

School of Health Sciences

Name of Student : ________________________________________________________________________________________________________________________________

Name & Address of School : St. Paul University Philippines, Mabini Street, Tuguegarao City_____________________________________________________________________
Accreditation Level (if any) : PAASCU LEVEL III______________________________________ Year Granted : ___________________________________________________
Date School / Program was Recognized : ______________________________________________ Number : ___________________________ Year : ______________________
First Course (if any) : ________________________________________ School Graduated From : ____________________________________ Year : ______________________
Year of Admission in the Bachelor of Science in Nursing Program : _________________________________________________________________________________________
Year Graduate (BSN Program) : _____________________________________________________________________________________________________________________

ACTUAL DELIVERIES

Date of Time of Gender Name of Type of Supervised by :

No. Case No. Diagnosis Name of Mother Age
Delivery Delivery of Baby Hospital Delivery Name & Signature of Qualified C.I.
1

Prepared by : Concurred by : Noted by : Approved by :

_______________________ ____________________________________ __________________________________________ SR. TRECELLA MAY MACALAM, SPC

Signature over Printed Name Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed : ________________________ Date Signed : _______________________________ Date Signed : _______________________
Degree : ____________________________ Degree : ___________________________________ Degree : ___________________________
a) PRC No. ____________________ a.) PRC No. ____________________________ a.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
b) PNA No. ____________________ b.) PNA No. ____________________________ b.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
c) ANSAP No. _________________ c.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________

St. Paul University Philippines

School of Health Sciences

Name of Student : ________________________________________________________________________________________________________________________________

Name & Address of School : St. Paul University Philippines, Mabini Street, Tuguegarao City_____________________________________________________________________
Accreditation Level (if any) : PAASCU LEVEL III______________________________________ Year Granted : ___________________________________________________
Date School / Program was Recognized : ______________________________________________ Number : ___________________________ Year : ______________________
First Course (if any) : ________________________________________ School Graduated From : ____________________________________ Year : ______________________
Year of Admission in the Bachelor of Science in Nursing Program : _________________________________________________________________________________________
Year Graduate (BSN Program) : _____________________________________________________________________________________________________________________

DELIVERIES ASSISTED

Date of Time of Gender Name of Type of Supervised by :

No. Case No. Diagnosis Name of Mother Age
Delivery Delivery of Baby Hospital Delivery Name & Signature of Qualified C.I.
1

Prepared by : Concurred by : Noted by : Approved by :

_______________________ ____________________________________ __________________________________________ SR. TRECELLA MAY MACALAM, SPC

Signature over Printed Name Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed : ________________________ Date Signed : _______________________________ Date Signed : _______________________
Degree : ____________________________ Degree : ___________________________________ Degree : ___________________________
a) PRC No. ____________________ a.) PRC No. ____________________________ a.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
b) PNA No. ____________________ b.) PNA No. ____________________________ b.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
c) ANSAP No. _________________ c.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________

St. Paul University Philippines

School of Health Sciences

Name of Student : ________________________________________________________________________________________________________________________________

Name & Address of School : St. Paul University Philippines, Mabini Street, Tuguegarao City_____________________________________________________________________
Accreditation Level (if any) : PAASCU LEVEL III______________________________________ Year Granted : ___________________________________________________
Date School / Program was Recognized : ______________________________________________ Number : ___________________________ Year : ______________________
First Course (if any) : ________________________________________ School Graduated From : ____________________________________ Year : ______________________
Year of Admission in the Bachelor of Science in Nursing Program : _________________________________________________________________________________________
Year Graduate (BSN Program) : _____________________________________________________________________________________________________________________

NEWBORN CARE

Date of Time of Gender Name of Type of Supervised by :

No. Case No. Diagnosis Name of Mother Age
Delivery Delivery of Baby Hospital Delivery Name & Signature of Qualified C.I.
1

Prepared by : Concurred by : Noted by : Approved by :

_______________________ ____________________________________ __________________________________________ SR. TRECELLA MAY MACALAM, SPC

Signature over Printed Name Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed : ________________________ Date Signed : _______________________________ Date Signed : _______________________
Degree : ____________________________ Degree : ___________________________________ Degree : ___________________________
a) PRC No. ____________________ a.) PRC No. ____________________________ a.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
b) PNA No. ____________________ b.) PNA No. ____________________________ b.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
c) ANSAP No. _________________ c.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________

St. Paul University Philippines

School of Health Sciences

Name of Student : ________________________________________________________________________________________________________________________________

Name & Address of School : St. Paul University Philippines, Mabini Street, Tuguegarao City_____________________________________________________________________
Accreditation Level (if any) : PAASCU LEVEL III______________________________________ Year Granted : ___________________________________________________
Date School / Program was Recognized : ______________________________________________ Number : ___________________________ Year : ______________________
First Course (if any) : ________________________________________ School Graduated From : ____________________________________ Year : ______________________
Year of Admission in the Bachelor of Science in Nursing Program : _________________________________________________________________________________________
Year Graduate (BSN Program) : _____________________________________________________________________________________________________________________

CORD DRESSING

Date of Time of Gender Name of Type of Supervised by :

No. Case No. Diagnosis Name of Mother Age
Delivery Delivery of Baby Hospital Delivery Name & Signature of Qualified C.I.
1

Prepared by : Concurred by : Noted by : Approved by :

_______________________ ____________________________________ __________________________________________ SR. TRECELLA MAY MACALAM, SPC

Signature over Printed Name Signature over Printed Name of Chief Nurse Signature over Printed Name of Clinical Coordinator Signature over Printed Name of Dean
Date Signed : ________________________ Date Signed : _______________________________ Date Signed : _______________________
Degree : ____________________________ Degree : ___________________________________ Degree : ___________________________
a) PRC No. ____________________ a.) PRC No. ____________________________ a.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
b) PNA No. ____________________ b.) PNA No. ____________________________ b.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________________ Valid Until: __________________
c) ANSAP No. _________________ c.) PRC No. ____________________
Valid Until: _________________ Valid Until: __________________