ACTUAL DELIVERY in St.

Victoria Hospital, Marikina City

Hospital, Municipal/ City/ Province

Prepared by: D.R. Form

Printed Name and Signature of Student SAUZA, APPLE CARABAT ACTUAL DELIVERY FORM

Patients
INITIAL ONLY D.R. Nurses on Duty
Date Performed SUPERVISED BY
Case Number PROCEDURE (Name and Signature)
and Clinical Instructor
(Not Applicable for PERFORMED (If Midwife on Duty,
Time Started Name and Signature
Birthing/ Lying-In Signature nor Required)
Clinics/ Homes)

March 6, 2023 Normal Spontaneous

BCM – 133907
6:26 PM Delivery Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN

March 15, 2023 Normal Spontaneous

BRL – 133962
4:00 PM Delivery Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN

March 18, 2023 Normal Spontaneous

CDC – 133974
9:00 AM Delivery Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
 IMMEDIATE NEWBORN CARE in Santana Maternity and Children’s Hospital, Inc., Antipolo City
Hospital, Municipal/ City/ Province

Prepared by: ICNB Form

Printed Name and Signature of Student SAUZA, APPLE CARABAT IMMEDIATE CARE OF THE
NEWBORN FORM

Patients Immediate Newborn

D.R. Nurses on Duty
INITIAL ONLY Cord Care Performed
Date Performed (Name and Signature) SUPERVISED BY
Case Number (Indicate where it is
and (If Midwife on Duty, Clinical Instructor
(Not Applicable for performed, e.g. D.R,
Time Started Signature nor Name and Signature
Birthing/ Lying-In Nursery, NICU, or
Required)
Clinics/ Homes) Home)
September 3,
2023 Neonatal Intensive Care
Baby Ko – 2608 Jerrold Macolor, RN John Reigner O. Orale, RN, MAN
Unit
7:07 AM
September 3,
2023 Neonatal Intensive Care
Baby Ko – 2613 Jerrold Macolor, RN John Reigner O. Orale, RN, MAN
Unit
10:30 PM
November 3,
2023 Neonatal Intensive Care
Baby Girl – 7932
Unit Jerrold Macolor, RN John Reigner O. Orale, RN, MAN
9:56 PM

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
 SCRUB NURSE in St. Victoria Hospital, Marikina City
Hospital, Municipal/ City/ Province

Prepared by: OR Form

Printed Name and Signature of Student SAUZA, APPLE CARABAT O.R SCRUB NURSE
Major

Date Performed Patients SUPERVISED BY

INITIAL ONLY PROCEDURE O.R. Nurses on Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

Exploratory Laparotomy
April 21, 2023 – Tissue Biopsy
YRC – 13413 Possible Diverting Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN
7:00 AM Colostomy Feeding
Tube Insertion

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
 SCRUB NURSE in Santana Maternity and Children’s Hospital, Inc., Antipolo City
Hospital, Municipal/ City/ Province

Prepared by: OR Form

Printed Name and Signature of Student SAUZA, APPLE CARABAT O.R SCRUB NURSE
Major

Date Performed Patients SUPERVISED BY

PROCEDURE O.R. Nurses on Duty
and INITIAL ONLY Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

October 22, 2023

TR – 63 Caesarean Section Maria Odessa Marigondon, RN John Reigner O. Orale, RN, MAN
10:20 AM

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
 SCRUB NURSE in Clinica Antipolo Hospital & Wellness Center, Inc., Antipolo City
Hospital, Municipal/ City/ Province

Prepared by: OR Form

Printed Name and Signature of Student SAUZA, APPLE CARABAT O.R SCRUB NURSE
Major

Date Performed Patients SUPERVISED BY

PROCEDURE O.R. Nurses on Duty
and INITIAL ONLY Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

April 5, 2024
LAB – 2404-027-601 Caesarean Section Charmaine A. Asico, RN Eraldo V. Nepomuceno, RN, MAN
10:30 AM

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
 SCRUB NURSE in St. Victoria Hospital, Marikina City
Hospital, Municipal/ City/ Province

Prepared by: OR Form

Printed Name and Signature of Student SAUZA, APPLE CARABAT O.R SCRUB NURSE
Minor

Date Performed Patients SUPERVISED BY

PROCEDURE O.R. Nurses on Duty
and INITIAL ONLY Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

March 20, 2023

ME – 19739 Ungiectomy
12:00 PM Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN

March 23, 2023 Bilateral

BJP – 19740
12:00 PM Varicocelectomy Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN

March 25, 2023

SR – 19741 Bilateral Orchiectomy
2:00 PM Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
SCRUB NURSE in St. Victoria Hospital, Marikina City
Hospital, Municipal/ City/ Province

Prepared by:
OR Form
Printed Name and Signature of Student SAUZA, APPLE CARABAT
O.R CIRCULATING NURSE

Date Performed Patients SUPERVISED BY

INITIAL ONLY PROCEDURE O.R. Nurses on Duty
and Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

April 13, 2023

CMC – 134118 Open Cholecystectomy Levi O. Ubalde, RN, MAN Gregorio C. Centeno, RN, MAN
8:00 PM

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units
 SCRUB NURSE in Santana Maternity and Children’s Hospital,
Inc., Antipolo City
Hospital, Municipal/ City/ Province

Prepared by:
OR Form
Printed Name and Signature of Student SAUZA, APPLE CARABAT
O.R CIRCULATING NURSE

Date Performed Patients SUPERVISED BY

PROCEDURE O.R. Nurses on Duty
and INITIAL ONLY Clinical Instructor
PERFORMED (Name and Signature)
Time Started Case Number Name and Signature

October 20, 2023 Caesarean Section +

SAC – 62
1:26 PM Bilateral Tubal Ligation Jerrold Macolor, RN John Reigner O. Orale, RN, MAN

November 15, 2023

EMR – 72 Caesarean Section Luisito Lopriego, RN
10:05 AM John Reigner O. Orale, RN, MAN

Noted by: ETHELDREDA G. SANTOS, RN, MAN Approved by: MA. TERESITA F. CERAPION, RN, MAN
(Print Name and Signature of Clinical Coordinator) (Print Name and Signature of Dean)
PRC I.D. No. 0348185 Valid Until: _July 27, 2025___ PRC I.D. No. 0139816 Valid Until: December 9, 2024 _
Date Document is signed: _________ Time: _______ Date Document is signed: __________ Time: ________
Specific Highest Nursing Degree Earned: Ph.D 25 units Specific Highest Nursing Degree Earned: Ed.D 36 units