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Ty5Ry
Lyceum of the Philippines University
Capitol Site, Batangas City
(043) 723-0706 loc 109-110/www.lyceumbatangas.edu.ph
PACUCOA ACCREDITED, LEVEL III Reaccredited Status, September 2012 – September 2017
SURGICAL SCRUB in BATANGAS MEDICAL CENTER/ KUMINTANG IBABA/BATANGAS CITY/ BATANGAS

O.R. Form 1B
O.R. CIRCULATING FORM

Prepared by:
Printed Name and Signature of Student GUERRERO ARNEL CLOSA

Date Performed and Time Started | Patient’s INITIALS Case Number | PROCEDURE PERFORMED | D.R Nurse On Duty | SUPERVISED BY | June 17, 20124:50 PM | SE12386 | Hip Disacrticulation | Marciano Luya | Suzette Florentino |

Concurred by: Approved by:

AMOR B. CALAYAN, RN RM MAN PhD CECILIA C. PRING, RN MAN PhD Chief Nurse Dean, College of Nursing

Lyceum of the Philippines University
Capitol Site, Batangas City
(043) 723-0706 loc 109-110/www.lyceumbatangas.edu.ph
PACUCOA ACCREDITED, LEVEL III Reaccredited Status, September 2012 – September 2017
SURGICAL SCRUB in BATANGAS HEALTH JESUS OF CARE HOSPITAL- NAZARETH/ GULOD ITAAS/ BATANGAS CITY/ BATANGAS

O.R. Form 1B
O.R. CIRCULATING FORM

Prepared by:
Printed Name and Signature of Student GUERRERO ARNEL CLOSA

Date Performed and Time Started | Patient’s INITIALS Case Number | PROCEDURE PERFORMED | D.R Nurse On Duty | SUPERVISED BY | January 23, 20132:30 PM | NM13534 | Laparoscopic Cholecystectomy with Intraoperative Cholangiogram | Melanie Sevilla | Gloria Ceniza | January 23, 20135:02 PM | DC23060 | Phacoemulsification Posterior Chamber Intra-Ocular Lens Cataract Surgery, Left Eye | Melanie Sevilla | Gloria Ceniza |

Concurred by: Approved by:

GLORIA G. CENIZA, RN MAN PhD CECILIA C. PRING, RN MAN PhD Chief Nurse Dean, College of
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