OUR LADY OF FATIMA UNIVERSITY

120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student: JACINTO, LESTER CONCEPCION_____________________________________________ _____

Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: 2000___ ____
Year Graduated (BSN Program): 2009____________________

I. MAJOR OPERATIONS
Signature of O.R.
Date of Name of Operation Type of Name of Name of O.R. Certified Clinical
No. Case No. Diagnosis Name of Hospital Certified Clinical
Operation Patient Performed Anesthesia Surgeon Instructor
Instructor

March 1, 060007348 Spinal Dr. Herminio Fatima University Medical

1. 2006 71
De Ala, Irene Cholelithiasis Cholecystectomy
Anesthesia Hernandez Center
Edna Co, RN,MAN

March 20, 060000075 Bilateral Cleft Lip, General Fatima University Medical
2. 2006 343
Javier, Julius
Complete
Cheiloplasty
Anesthesia
Dr. Nixon See
Center
Edna Co, RN,MAN

Pregnancy Uterine Full Term Low Transverse

December 4, Jennalyn 39 weeks Age of Gestation, Spinal Dra. Irene
3. 2006
01-43-44
Cabrera Cephalic in Labor, Cephalo-
Classical
Anesthesia Ambalada
Santos General Hospital Sylvia Lopez RN,MAN
Pelvic Disproportion Caesarian Section

December 6, 01-42-56 Lourdes Spinal Dr. Erick

4. 2006 Fernando
Chronic Renal Bleeding Nephrectomy
Anesthesia Mendiola
Santos General Hospital Sylvia Lopez RN,MAN

01- 43-79 Exploratory

December Spinal Dr. Lazaro
5. 12, 2006
Romeo Garay Ruptured Appendicitis Laparotomy with
Anesthesia Tapang
Santos General Hospital Sylvia Lopez RN,MAN
Appendectomy
AIDA V. GARCIA, RN, MAN
Noted by: ELSA PACHECO, RN, MAN__________________ Signature over printed name of Clinical Coordinator
Signature over printed name of Chief Nurse Date Signed: LURCELI L. SANTOS, RN,RM MAN
Date Signed: _ Degree: BSN, MAN Signature over printed name of Dean
Degree: ____BSN, MAN _____ ______ a.) PRC NO : 0196716 _____ Date Signed: _
a.) PRC NO: 0125729 ______ Valid Until: MARCH 30, 2011 Degree: ______ BSN, __MAN
Valid Until: OCTOBER 13, 2010_____ b.) PNA NO: 022841 a.) PRC NO: ___ 0010878___
b.) PNA NO: 34267 _______ Valid Until: DECEMBER 2010 Valid Until: __2011
Valid Until: OCTOBER 8, 2010 ______ b.) PNA NO: ___3018
Valid Until: __LIFETIME ______
c.) ADPCN NO: _0635
Valid Until: DECEMBER 2010
 OUR LADY OF FATIMA UNIVERSITY
120 Mc Arthur Highway Marulas, Valenzuela City
Name of Student: JACINTO, LESTER CONCEPCION
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: 2000
Year Graduated (BSN Program): 2009

II. MINOR OPERATIONS

Name of O.R. Signature of O.R.
Date of Name of Operation Type of Name of
No. Case No. Diagnosis Name of Hospital Certified Clinical Certified Clinical
Operation Patient Performed Anesthesia Surgeon
Instructor Instructor
IM
November Intravenous Dr. Roberto Fatima University
1. 03000003 Susana Cortez Mild Esophagitis Gastroscopy Medical Center
Edna Co, RN,MAN
6,2003 Sedation Lopez
1003
Phaco Emulsification
EY
November Roque, Mature Cataract, Left with Posterior Local Dr. Noel Fatima University
2. 03000003 Medical Center
Edna Co, RN,MAN
6,2003 Reynoso Jr. Eye Chamber Intraocular Anesthesia Laxamana
1112
Lens, Left Eye
Dr. Jonathan
November G-00- Retained Lens Local Fatima University
3. Martinez, Noel Phacofrag, Right Eye Feliciano Medical Center
Edna Co, RN,MAN
7,2003 32053 Material, Right Eye Anesthesia
SU Traumatic Wound Debridement
November Local Fatima University
4. 03000003 Junie, Bonol Amputation 2nd to 5th and Completion Dr. Celso Fidel Medical Center
Edna Co, RN,MAN
13,2003 Anesthesia
1578 digit right hand Amputation
September Jacinto Avulsion of Proximal Wound Cleansing Local Dr. Joseph Fatima University
5. 05737 Medical Center
Edna Co, RN,MAN
12, 2005 Hernandez Anterior Tibia Suturing Dressing Anesthesia Aniciete

Noted by:

ELSA PACHECO, RN, MAN ___________

Signature over printed name of Chief Nurse AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM MAN
Date Signed: _ Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Degree: ____BSN, MAN_______ ______ Date Signed: Date Signed: _____
a.) PRC NO: 0125729______ ______ Degree: BSN, MAN Degree: BSN, MAN _____
Valid Until: OCTOBER 13, 2010_____ a.) PRC NO: 0196716 a.) PRC NO: 0010878 _____
b.) PNA NO: 34267______ _______ Valid Until: MARCH 2011 Valid Until 2011 _____
Valid Until: OCTOBER 8, 2010 ______ b.) PNA NO: 022841 b.) PNA NO: 3018 _____
Valid Until: DECEMBER 2010 Valid Until: LIFETIME _____
c.) ADPCN NO: 0635 _______
Valid Until: 2010 _____
 OUR LADY OF FATIMA UNIVERSITY
120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student:_JACINTO, LESTER CONCEPCION

Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: 2000
Year Graduated (BSN Program): 2009___

III. ACTUAL DELIVERIES

Case Name of Date of Time of Gender of Supervised By: Signature of
No. Diagnosis Age Name of Hospital Type of Delivery
No. Mother Delivery Delivery Baby O.R. /DR Clinical Instructor
Realina A. Peralta RM, RN
Pregnancy Uterine Full Term Dr. Jose Fabella Normal
1. 03044354 Cephalic in Labor Gravida 5 Chico, Nenita 40 February 24, 2003 12:03 AM Female Memorial Hospital Spontaneous
Para 5 Delivery
Realina A. Peralta RM, RN
Pregnancy Uterine Full Term Dr. Jose Fabella Normal
Zamora,
2. 03044480 Cephalic in Labor Gravida 3 Monette
25 February 24, 2003 2:23 AM Male Memorial Hospital Spontaneous
Para 3 Delivery
Pregnancy Uterine Full Term Dr. Jose Fabella Normal Realina A. Peralta RM, RN
Pacheco,
3. 03044517 Cephalic in Labor Gravida 4 Yolanda
23 February 26, 2003 12:30 AM Male Memorial Hospital Spontaneous
Para 3 Delivery
Pregnancy Uterine Full Term Dr. Jose Fabella Normal Realina A. Peralta RM, RN
Dalumatan,
4. 03044527 Cephalic in Labor Gravida 1 Leticia
23 February 26, 2003 3:10 AM Male Memorial Hospital Spontaneous
Para 1 Delivery
Pregnancy Uterine Full Term Dr. Jose Fabella Normal Realina A. Peralta RM, RN
Sunor,
5. 03042101 Cephalic in Labor Gravida 1 Jheaneth
21 February 27, 2003 3:05 AM Male Memorial Hospital Spontaneous
Para 1 Delivery
Noted by:

MARIE THERESE A. PACABIS RN, RM, MAN AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM, MAN
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: BSN, MAN, RM Degree: BSN, MAN Degree: BSN, MAN
a.) PRC NO: 003956_______________ a.) PRC NO: 0196716 a.) PRC NO: 0010878
Valid Until: October 12, 2012 ____ Valid Until: MARCH 2011 Valid Until: 2011
b.) PNA NO: 18153 b.) PNA NO: 022841 b.) PNA NO: 3018
Valid Until: LIFETIME __ Valid Until: DECEMBER 2010 Valid Until: LIFETIME
OUR LADY OF FATIMA UNIVERSITY c.) ADPCN NO: 0635
Valid Until: 2010
 120 Mc Arthur Highway Marulas, Valenzuela City

Name of Student: _ JACINTO, LESTER CONCEPCION __________________

Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: 2000
Year Graduated (BSN Program): 2009 _______
IV. DELIVERIES ASSISTED
Name of Date of Time of Gender Name of Supervised By: Signature of O.R.
No. Case No. Diagnosis Age Type of Delivery
Mother Delivery Delivery of Baby Hospital /DR Clinical Instructor
Dr. Jose Fabella
Pregnancy Uterine Full Term
February 26, Memorial Normal Spontaneous
1. 03043014 Cephalic in Labor Gravida 2 Drue, Susan 23 11:00 PM Female Realina A. Peralta RM, RN
2003 Hospital Delivery
Para 2
Dr. Jose Fabella
Pregnancy Uterine Full Term
Taguinod, February 28, Memorial Normal Spontaneous
2. 03044519 Cephalic in Labor Gravida 1 22 1:58 AM Female Realina A. Peralta RM, RN
Judelyn 2003 Hospital Delivery
Para 1
Dr. Jose Fabella
Pregnancy Uterine Full Term
Posadas, February 28, Memorial Normal Spontaneous
3. 3044581 Cephalic in Labor Gravida 1 15 4:00 AM Female Realina A. Peralta RM, RN
Renalyn 2003 Hospital Delivery
Para 1
Pregnancy Uterine Full Term Dr. Jose Fabella
Cephalic Gravida 2 Para 2 non February 27, Normal Spontaneous
4. 30364771 spontaneous delivery to twin baby
Kempis, Juliet 21 A. 3:30 AM Female Memorial Realina A. Peralta RM, RN
2003 Delivery
girls with episiotomy. Hospital
Pregnancy Uterine Full Term Dr. Jose Fabella
Cephalic Gravida 2 Para 2 non February 27, Normal Spontaneous
5. spontaneous delivery to twin baby
Kempis, Juliet 21 B. 3:45 AM Female Memorial Realina A. Peralta RM, RN
2003 Delivery
girls with episiotomy. Hospital
Noted by:
MARIE THERESE A. PACABIS RN, RM,MAN AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM, MAN
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: BSN, MAN, RM Degree: BSN, MAN Degree: BSN, MAN
a.) PRC NO: 003956_______________ a.) PRC NO: 0196716 a.) PRC NO: 0010878
Valid Until: October 12, 2012 ____ Valid Until: MARCH 2011 Valid Until: 2011
b.) PNA NO: 18153 b.) PNA NO: 022841 b.) PNA NO: 3018
Valid Until: LIFETIME __ Valid Until: DECEMBER 2010 Valid Until: LIFETIME
c.) ADPCN NO: 0635
OUR LADY OF FATIMA UNIVERSITY Valid Until: 2010
120 Mc Arthur Highway Marulas, Valenzuela City
Name of Student: JACINTO, LESTER CONCEPCION
Name and Address of School: OUR LADY OF FATIMA UNIVERSITY, 120 Mc Arthur Highway, Marulas, Valenzuela City
Accreditation Level (if any): PACUCOA LEVEL II Year Granted: APRIL 10, 2002
Date School/Program was Recognized: JUNE 09, 1980 Number: 025 Year: 1980
First Course (if any): NOT APPLICABLE School Graduated From: NOT APPLICABLE Year: NOT APPLICABLE
Year of Admission in the Bachelor of Science in Nursing Program: 2000 ___________
Year Graduated (BSN Program): 2009 _______

V. CORD DRESSING
Gender of Supervised By: Signature of O.R. /DR
No. Case No. Date Performed Name of Baby Name of Mother Age Name of Hospital
Baby Clinical Instructor

Dr. Jose Fabella Memorial

1. 03044519 February 28, 2003 Baby Tanguinod Female Taguinod, Judelyn 22 Realina A. Peralta RM, RN
Hospital

Dr. Jose Fabella Memorial

2. 3044581 February 28, 2003 Baby Posadas Female Posadas, Renalyn 15 Realina A. Peralta RM, RN
Hospital

Dr. Jose Fabella Memorial

3. 03043014 February 26, 2003 Baby Dreu Female Drue, Susan 23 Realina A. Peralta RM, RN
Hospital

Dr. Jose Fabella Memorial

4. 30364771 February 27, 2003 A. Baby Kempis Female Kempis, Juliet 21 Realina A. Peralta RM, RN
Hospital

Dr. Jose Fabella Memorial

5. February 27, 2003 B. Baby Kempis Female Kempis, Juliet 21 Realina A. Peralta RM, RN
Hospital

Noted by:

AIDA V. GARCIA, RN, MAN LURCELI L. SANTOS, RN, RM, MAN

MARIE THERESE A. PACABIS RN, RM,MAN Signature over printed name of Clinical Coordinator Signature over printed name of Dean
Signature over printed name of Chief Nurse Date Signed: Date Signed:
Date Signed: Degree: BSN, MAN Degree: BSN, MAN
Degree: BSN, MAN, RM a.) PRC NO: 0196716 a.) PRC NO: 0010878
a.) PRC NO: 003956_______________ Valid Until: MARCH 2011 Valid Until: 2011
Valid Until: October 12, 2012 ____ b.) PNA NO: 022841 b.) PNA NO: 3018
b.) PNA NO: 18153 Valid Until: DECEMBER 2010 Valid Until: LIFETIME
Valid Until: LIFETIME __ c.) ADPCN NO: 0635
Valid Until: 2010
-

3. ONCE SIGNED BY CI and NOD,

The CI will submit the forms to CAS 105 for

signing w/ Mam Garcia & Dean every cut off [Link] are required to accomplish and
submit this form to their Clinical Instructor
NCM 105 [Link] release the forms to GRP
LEADER EVERY WED AND FRI AT PJP 5TH FLOOR 1 form per hospital
or PJP FACULTY ROOM AT 5PM TO 6PM…

2. Clinical instructor

-will check the data

-If correct, to be signed by CI and Nurse On Duty