Final Caseload Forms Blank (2)

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8/8/2019 Final Caseload Forms Blank (2)

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UNIVERSITY OF PANGASINANCOLLEGE OF NURSING

Arellano St., Dagupan CityPhone 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)

I. MAJOR OPERATION

No.DATE of

OPERATION

TIME of OPERATION

STARTED-ENDED

PATIENT¶SINITIALS DIAGNOSIS OPERATION

PERFORMED

TYPE of ANESTHESI

ANAME of SURGEON NAME of

HOSPITALName & Sign

ClinicCASE NO.

1 May 5, 2010 12:25 pm-12:50 pmM.J.C

Status Post Partum, Normal SpontaneousDelivery, With VaginalLaceration, Gravid 2Para 2 (1-0-0-1)

Perineorrhaphy Local Dr. Frederick G. Lalas MapCHMaria Leah G. B00894

LEGEND: MapCH ± Mapandan Community Hospital

Noted by: ZENAIDA M. BAUTISTA Clinical Coordinator

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

Concurred by: GRACE Z. JOVELIANOSChief Nurse

PRC I.D. No.: 0064042 Valid Until: SepPNA No.: 029073 Valid Until: OcDate document is signed:

Please specify Highest Nursing Degree Earned: BSN

Approved by: MARIA TERESA R. FAJARDean

PRC I.D. No.: 0160104 Valid Until: SepPNA No.: 013739 ________ Valid Until: OctADPCN No.: Valid Until:Date document is signed: Please specify Highest Nursing Degree Earned:

Supervised by: MARIA LEAH G. BARANGAN Clinical Instructor

Date signed:Degree: BSN-RNPRC I.D. No.: 0392061 Valid Until: September 27, 2012PNA No.: 031851 Valid Until: October 31, 2010

NAME OF STUDENT: OVIEDO, Joan Ticsay

First course (if any): Bachelor of Science in Physical TherapySchool graduated from: Lyceun Northwestern University,Dagupan City, Pangasinan

Year: 2002Year of admission in the BSN Program: June 2006Year graduated from BSN Program: 2011

Prepared by:

JOAN T. OVIEDO Student

UNIVERSITY OF PANGASINAN

COLLEGE OF NURSINGArellano St., Dagupan CityPhone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph

II. MINOR OPERATION

No. DATE of OPERATION

TIME of OPERATION

STARTED-ENDED

PERFORMEDTYPE of

ANESTHESIA NAME of SURGEON NAME of HOSPITAL Qua

CASE NO.

1 June 8, 201012:25 pm-12:35 pm

K.C.DLacerated Wound

Right ArmSuturing Local Dr. Virginia C. Petrola LDH

Flor12419

LEGEND: LDH - Lingayen District Hospital (Primary)

Noted by: PROF. ZENAIDA M. BAUTISTA Clinical Coordinator

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

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

Approved by: PROF. MARIA TERESA R. FAJARDean

PRC I.D. No.: 0160104 Valid Until: SeptemPNA No.: 013739 Valid Until: October ADPCN No.: Valid Until:Date document is signed: Please specify Highest Nursing Degree Earned:

Supervised by: FLORENCE LOMIBAO Clinical Instructor

Date signed:Degree: ________ PRC I.D. No.: Valid Until:PNA No.: Valid Until:

NAME OF STUDENT: OVIEDO, Joan Ticsay

First course (if any): Bachelor of Science in Physical TherapySchool graduated from: Lyceun Northwestern University,Dagupan City, Pangasinan

Prepared by:

UNIVERSITY OF PANGASINANCOLLEGE OF NURSINGArellano 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)

II. MINOR OPERATIONS

No. DATE of OPERATION

TIME of OPERATION

STARTED-ENDED

PERFORMEDTYPE of

ANESTHESIA NAME of SURGEON NAME of HOSPITAL

Name & SCli

CASE NO.

1 April 26, 20109:00 am-9:30 am N.D.T Redundant

PrepuceCircumcision Local Dr. Frederick G. Lalas MapCH

Maria Leah03944

2 April 29, 20102:00 pm-2:02 pm D.T.S Abscess Right

ThumbIncision And

Drainage None Dr. Erl danielsson P. Javier MapCH

Maria Leah03956LEGEND: MapCH - Mapandan Community Hospital (Primary)

PRC I.D. No.: 0133422 Valid Until: July 27, 2011

PNA No.: 029069 ________ Valid Until: October 31, 2010Date document is signed: Time:Please specify Highest Nursing Degree Earned:

Concurred by: GRACE Z. JOVELIANOS

Chief NursePRC I.D. No.: 0064042 Valid Until: SePNA No.: 029073 Valid Until: OcDate document is signed: Please specify Highest Nursing Degree Earned: BSN

Approved by: MARIA TERESA R. FAJARDean

PRC I.D. No.: 0160104 Valid Until: Se

PNA No.: 013739 ________ Valid Until: OctADPCN No.: Valid Until:Date document is signed: Please specify Highest Nursing Degree Earned:

Supervised by: MARIA LEAH G. BARANGAN Clinical Instructor

Date signed:

Degree: BSN-RNPRC I.D. No.: 0392061 Valid Until: September 27, 2012PNA No.: 031851 Valid Until: October 31, 2010

NAME OF STUDENT: OVIEDO, Joan Ticsay First course (if any): Bachelor of Science in Physical TherapySchool graduated from: Lyceun Northwestern University,Dagupan City, Pangasinan

Prepared by:

III. ACTUAL DELIVERIESNo. DIAGNOSIS

MOTHER¶S INITIALSAGE DATE of DELIVERY TIME of

DELIVERY GENDER of BABY TYPEof DELIVERY

NAME of HOSPITAL

Name CASE NO.

1Pregnancy Uterine

Full Term, 37 weeksAnd 1/7 days

V.B.M35 June 15, 2010 12:20 pm Baby Girl Normal Spontaneous

DeliveryManCH Florenc

LEGEND: ManCH ± Manaoag Community Hospital

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

Concurred by:Chief Nurse

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

Approved by: PROF. MARIA TERESA R. FAJARDDean

PRC I.D. No.: 0160104 Valid Until: SeptPNA No.: 013739 Valid Until: OctADPCN No.: Valid Until:Date document is signed:

Please specify Highest Nursing Degree Earned:

Supervised by: FLORENCE LOMIBAO Clinical Instructor

Date signed:Degree: ________ PRC I.D. No.: Valid Until:PNA No.: Valid Until:

Prepared by:

IV. ASSISTED DELIVERIESNo. DIAGNOSIS

MOTHER¶S INITIALSAGE DATE of

DELIVERY TIME of

DELIVERY GENDER of BABY TYPEof DELIVERY

NAME of HOSPITAL QuaCASE NO.

LEGEND:

PRC I.D. No.: 0160104 Valid Until: SepPNA No.: 013739 Valid Until: OctADPCN No.: Valid Until:Date document is signed: Please specify Highest Nursing Degree Earned:

Supervised by:Clinical Instructor

Date signed:Degree:PRC I.D. No.: Valid Until:PNA No.: Valid Until:

Prepared by:

UNIVERSITY OF PANGASINANCOLLEGE OF NURSING

Arellano St., Dagupan CityPhone No.: (075)522-5635-37; Fax No.: (075)522-2496; E-mail: registrar@upang.edu.ph; Website: http://www.upang.edu.ph

V. IMMEDIATE NEWBORN CORD CARE

No. DATE PERFORMEDTIME OF

DELIVERYBABY¶S INITIALS

GENDER of BABY MOTHER¶S INITIALS AGE NAME of HOSPITAL QualCASE NO.

1 August 16, 2010 4:21 pmBaby R

Female K.S.R 26Bam10-09

LEGEND: Dr. Marcelo M. Chan Memorial Hospital

PRC I.D. No.: 0160104 Valid Until: SepPNA No.: 013739 Valid Until: OctADPCN No.: Valid Until:Date document is signed: Please specify Highest Nursing Degree Earned:

Supervised by:Clinical Instructor

Date signed:Degree:PRC I.D. No.: Valid Until:PNA No.: Valid Until:

NAME OF STUDENT: First course (if any): Bachelor of Science in Physical TherapySchool graduated from: Lyceun Northwestern University,Dagupan City, Pangasinan

Prepared by:

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