St. Anthony College of Roxas City, Inc.
ODC Form 1A
San Roque Extension, Roxas City 5800 Capiz, Philippines ACTUAL DELIVERY
Telephone No.: (036) 621-0431 local 163 FORM
Fax No.: (036) 621-4185
Website: [Link]
Government Recognition No. 012; Series of 1982 – July 6, 1981
ACTUAL DELIVERY NAME OF FACILITY
in
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of FIRST NAME, MIDDLE NAME, & LAST NAME (e.g AQUILA ZILPAH CELIS
Student: ANDUTAN)
Patient’s INITIAL only D.R. Nurse On Duty
Date Performed Case Number SUPERVISED BY
PROCEDURE (Name and Signature)
and (not applicable for Clinical Instructor
PERFORMED (If Midwife on Duty,
Time of Delivery Birthing/ Lying-in Name and Signature
Signature not Required)
Clinics/Homes)
MARCH 07, 2023 J.A.V. NORMAL SPONTANEOUS EVANGELINE J. DETANOY, MABEL ALONA A. MACAHILIG, MSN,
7:21 AM 1880 VAGINAL DELIVERY RN RN
Noted Approved
by: EDRELYN A. VENTURANZA, MAN, RN by: RUBILYN B. SUMAYLO, PhD, RN, LPT
(Print Name and Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D Valid Dean, PRC I.D
No. 0202539 Until: June 29, 2024 No. 0348415 Valid Until: April 8, 2026
Date document is Date document is
signed: Time: signed: Time:
Please specify Highest Nursing Degree Master of Arts in Nursing Specify Highest Nursing Degree Earned: Doctor of Philosophy
St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: [Link]
Government Recognition No. 012; Series of 1982 – July 6, 1981
ODC Form 1B
Earned:
ASSISTED Delivery
FORM
(STRICTLY NO DESIGNATES)
ACTUAL DELIVERY NAME OF FACILITY
in
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of FIRST NAME, MIDDLE NAME, & LAST NAME (e.g AQUILA ZILPAH CELIS
Student: ANDUTAN)
Patient’s INITIAL
only PROCEDURE D.R. Nurse On Duty
Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(not applicable for (If Midwife on Duty,
Time of Delivery Name and Signature
Birthing/ Lying-in ASSISTED DELIVERY Signature not Required)
Clinics/Homes)
MARCH 07, 2023 L.V. NORMAL SPONTANEOUS MABEL ALONA A. MACAHILIG, MSN,
9:27 AM 1895 VAGINAL DELIVERY EVANGELINE J. DETANOY, RN RN
Noted Approved
by: EDRELYN A. VENTURANZA, MAN, RN by: RUBILYN B. SUMAYLO, PhD, RN, LPT
St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: [Link]
Government Recognition No. 012; Series of 1982 – July 6, 1981
(Print Name and (Print Name and
Signature) Signature)
Clinical Coordinator, PRC I.D Valid Dean, PRC I.D
No. 0202539 Until: June 29, 2024 No. 0348415 Valid Until: April 8, 2026
Date document is Date document is
signed: Time: signed: Time:
Please specify Highest Nursing Degree ODC Form 1C
Earned: Master of Arts in Nursing Specify Highest Nursing Degree Earned: Doctor of CORD
Philosophy
CARE FORM
(STRICTLY NO DESIGNATES)
IMMEDIATE NEWBORN CORD NAME OF FACILITY
CARE in
Hospital/Home/Lying-In Clinic, Municipality/City/Province
Prepared by:
Printed Name and Signature of FIRST NAME, MIDDLE NAME, & LAST NAME (e.g AQUILA ZILPAH CELIS
Student: ANDUTAN)
Patient’s INITIAL only Immediate Newborn
Cord Care D.R. Nurse On Duty
Date Performed SUPERVISED BY
Case Number PERFORMED (Name and Signature)
and Clinical Instructor
(not applicable for Birthing/ Indicate where performed (If Midwife on Duty,
Time of Delivery Name and Signature
Lying-in Clinics/Homes) e.g. D.R., Nursery, NICU, or Signature not Required)
Home
JANUARY 09, 2023 BABY GIRL U. EVANGELINE J. DETANOY, MABEL ALONA A. MACAHILIG, MSN,
DELIVERY ROOM
8:43 AM 0237 RN RN
JANUARY 11, 2023 BABY GIRL D. EVANGELINE J. DETANOY, MABEL ALONA A. MACAHILIG, MSN,
DELIVERY ROOM
2:57 PM 0296 RN RN
St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: [Link]
Government Recognition No. 012; Series of 1982 – July 6, 1981
Noted Approved
by: EDRELYN A. VENTURANZA, MAN, RN by: RUBILYN B. SUMAYLO, PhD, RN, LPT
(Print Name and
Signature) (Print Name and Signature)
Clinical Coordinator, PRC I.D Valid Dean, PRC I.D
No. 0202539 Until: June 29, 2024 No. 0348415 Valid Until: April 8, 2026
Date document is Date document is
signed: Time: signed: Time:
Please specify Highest Nursing Degree Specify Highest Nursing Degree
Earned: Master of Arts in Nursing Earned: Doctor of Philosophy
(STRICTLY NO DESIGNATES)
ODC Form 2A
O.R. SCRUB FORM
Major
SURGICAL SCRUB
in NAME OF FACILITY
Hospital, Municipality/City/Province
Prepared by:
Printed Name and Signature of FIRST NAME, MIDDLE NAME, & LAST NAME (e.g AQUILA ZILPAH CELIS
Student: ANDUTAN)
Date Performed Patient’s INITIAL only O.R. Nurse On Duty SUPERVISED BY
and
SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
Time Started Case Number
PERFORMED Name and Signature
OCTOBER 13, 2022 M.A.C. PHACOEMULSIFICATION WITH MA. DAREN D. DE JUSTO, MAN,
ANDREA MAY I. MEDINA, RN
2:50 PM 3226449 POSTERIOR CHAMBER RN
St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: [Link]
Government Recognition No. 012; Series of 1982 – July 6, 1981
INTRAOCULAR LENS
INSERTION LEFT EYE
JANUARY 31, 2023 D.B. MA. DAREN D. DE JUSTO, MAN,
COLONOSCOPY DINA JOY E. ATANDO, RN
9:10 AM 328090 RN
FEBRUARY 06,
L.D. LAPAROSCOPIC MA. DAREN D. DE JUSTO, MAN,
2023 RICARDO O. GARCES III, RN
1182018474 CHOLECYSTECTOMY RN
1:19 PM
Noted Approved
by: EDRELYN A. VENTURANZA, MAN, RN by: RUBILYN B. SUMAYLO, PhD, RN, LPT
(Print Name and (Print Name and
Signature) Signature)
Clinical Coordinator, PRC I.D Valid Dean, PRC I.D
No. 0202539 Until: June 29, 2024 No. 0348415 Valid Until: April 8, 2026
Date document is Date document is
signed: Time: signed: Time:
Please specify Highest Nursing Degree Specify Highest Nursing Degree
Earned: Master of Arts in Nursing Earned: Doctor of Philosophy
(STRICTLY NO DESIGNATES)
ODC Form 2B
SURGICAL SCRUB O.R. CIRCULATING
in NAME OF FACILITY FORM
Hospital, Municipality/City/Province
Prepared by:
Printed Name and Signature of FIRST NAME, MIDDLE NAME, & LAST NAME (e.g AQUILA ZILPAH CELIS
Student: ANDUTAN)
Date Performed Patient’s INITIAL only O.R. Nurse On Duty SUPERVISED BY
St. Anthony College of Roxas City, Inc.
San Roque Extension, Roxas City 5800 Capiz, Philippines
Telephone No.: (036) 621-0431 local 163
Fax No.: (036) 621-4185
Website: [Link]
Government Recognition No. 012; Series of 1982 – July 6, 1981
and
Case Number
SURGICAL PROCEDURE (Name and Signature) Clinical Instructor
Time Started PERFORMED Name and Signature
PHACOEMULSIFICATION WITH
OCTOBER 06, 2022 G.L. POSTERIOR CHAMBER MA. DAREN D. DE JUSTO, MAN,
ANDREA MAY I. MEDINA, RN
11:00 AM 326335 INTRAOCULAR LENS INSERTION RN
LEFT EYE
TOTAL ABDOMINAL
NOVEMBER 11,
R.V. HYSTERECTOMY UNILATERAL JOHNRITH MONICA D. OLANO, MA. DAREN D. DE JUSTO, MAN,
2022
1182018376 SALPINGO-OOPHORECTOMY RN RN
10:00 AM
WITH APPENDECTOMY
JANUARY 24, 2023 J.A. MA. DAREN D. DE JUSTO, MAN,
COLONOSCOPY JOPAZ E. TAN, RN
11:25 AM 327973 RN
Noted Approved
by: EDRELYN A. VENTURANZA, MAN, RN by: RUBILYN B. SUMAYLO, PhD, RN, LPT
(Print Name and (Print Name and
Signature) Signature)
Clinical Coordinator, PRC I.D Valid Dean, PRC I.D
No. 0202539 Until: June 29, 2024 No. 0348415 Valid Until: April 8, 2026
Date document is Date document is
signed: Time: signed: Time:
Please specify Highest Nursing Degree
Earned: Master of Arts in Nursing Specify Highest Nursing Degree Earned: Doctor of Philosophy
(STRICTLY NO DESIGNATES)