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Updated HTU PRC Form
The document appears to be a record of clinical experiences for a nursing student. It includes sections listing major operations, minor procedures, deliveries handled and assisted with, and cord dressings. For each experience, it records patient details, date, type of procedure or surgery, anesthesia used, treating physicians and hospital. Signatures of the clinical supervisor, chief nurse and dean are included to verify the documented experiences.
Updated HTU PRC Form
- 1. NAME OF STUDENT:______________________________________________________________________________________________________________ First Course (if any): _______________________________________________ ____ __________________ Name and Address of School: Holy Trinity University ______________________________________________________________________________________ School Graduated From: __________________________________________ _________________________ Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________ Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________ Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________ Year Graduated (BSN Program):____________________________________ _________________________ Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________ I. MAJOR OPERATIONS Date of Case Type of Name of Name of Name of Signature of No. Name of Patient Medical Diagnosis Type of Surgery Operation No. Anesthesia Surgeon Hospital Qualified C.I. Qualified C.I. 1. 2. 3. 4. 5. Supervised By:_________________________________________________________ ____________________ (Signature over printed name of Clinical Supervisor) Date Signed:____________________________________________________________ ____________________ Degree:BSN, RN, MAN _______________________________________________________________________ PRC No: _______________________________ Valid Until: _______________ _________________________ PNA No: _______________________________ Valid Until: _______________ _________________________ Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________ Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________ (Signature over printed name of Chief Nurse) (Signature over printed name of Dean) Date Signed: __________________________________________________________________________________ Date Signed: _______________________________________________________________________________ Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________ Degree: BSN, RN, PRC No: _______________________________ Valid Until: ____________________________________________ PRC No: ______________________________ Valid Until_______________________ _____________________ PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________ PNA No: ______________________________Valid Until: ______________________ _____________________ ADPCN No: ___________________________ Valid Until: ___________________________________________
- 2. NAME OF STUDENT:______________________________________________________________________________________________________________ First Course (if any): _______________________________________________ ____ __________________ Name and Address of School: Holy Trinity University ______________________________________________________________________________________ School Graduated From: __________________________________________ _________________________ Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________ Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________ Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________ Year Graduated (BSN Program):____________________________________ _________________________ Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________ II. MINOR SCRUBS Date of Case Type of Name of Name of Name of Signature of No. Name of Patient Medical Diagnosis Type of Surgery Operation No. Anesthesia Surgeon Hospital Qualified C.I. Qualified C.I. 1. 2. 3. 4. 5. Supervised By:_________________________________________________________ ____________________ (Signature over printed name of Clinical Supervisor) Date Signed:____________________________________________________________ ____________________ Degree:BSN, RN, MAN _______________________________________________________________________ PRC No: _______________________________ Valid Until: _______________ _________________________ PNA No: _______________________________ Valid Until: _______________ _________________________ Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________ Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________ (Signature over printed name of Chief Nurse) (Signature over printed name of Dean) Date Signed: __________________________________________________________________________________ Date Signed: _______________________________________________________________________________ Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________ Degree: BSN, RN, PRC No: _______________________________ Valid Until: ____________________________________________ PRC No: ______________________________ Valid Until_______________________ _____________________ PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________ PNA No: ______________________________Valid Until: ______________________ _____________________ ADPCN No: ____________________________ Valid Until: __________________________________________
- 3. NAME OF STUDENT:._____________________________________________________________________________________________________________ First Course (if any): _______________________________________________ ____ __________________ Name and Address of School: Holy Trinity University ______________________________________________________________________________________ School Graduated From: __________________________________________ _________________________ Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________ Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________ Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________ Year Graduated (BSN Program):____________________________________ _________________________ Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________ III. DELIVERIES HANDLED Date of Time of Signature of No. Case No. Name and Age of Patient Type of Delivery Gender of Baby Name of Hospital Name of Qualified C.I. Delivery Delivery Qualified C.I. 1. 2. 3. 4. 5. Supervised By:_________________________________________________________ __________________ (Signature over printed name of Clinical Supervisor) Date Signed:____________________________________________________________ _________________ Degree:BSN, RN, MAN _____________________________________________________________________ PRC No: ______________________________ Valid Until: _______________ _______________________ PNA No: ______________________________ Valid Until: _______________ _______________________ Noted by: AGNES B. PALAO, RN, MAN, Ph.D. ___________________________________________ (Signature over printed name of Chief Nurse) Noted By: _ MARIA CELINA G. CASIS, RN, MSN ________________________________ Date Signed: __________________________________________________________________________________ (Signature over printed name of Dean) Degree:BSN, RN, MPA, Ph.D. _____________________________________________________________________ Date Signed: _____________________________________________________________________________ PRC No: ______________________________ Valid Until: _____________________________________________ BSN, RN, MSN _____________________________________________________________________ Degree: PNA No: 12564 _________________________ Valid Until: Lifetime Member___ ____________________________ PRC No: _____________________________ Valid Until_______________________ __________________ PNA No: ______________________________Valid Until: ______________________ ___________________ ADPCN No: Valid Until: ________________________________________
- 4. NAME OF STUDENT:______________________________________________________________________________________________________________ First Course (if any): _______________________________________________ ____ __________________ Name and Address of School: Holy Trinity University ______________________________________________________________________________________ School Graduated From: __________________________________________ _________________________ Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________ Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________ Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________ Year Graduated (BSN Program):____________________________________ _________________________ Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________ IV. DELIVERIES ASSISTED Date of Time of Gender of Signature of No. Case No. Name and Age of Patient Type of Delivery Name of Hospital Name of Qualified C.I. Delivery Delivery Baby Qualified C.I. 1. 2. 3. 4. 5. Supervised By:_________________________________________________________ ____________________ (Signature over printed name of Clinical Supervisor) Date Signed:____________________________________________________________ ____________________ Degree:BSN, RN, MAN _______________________________________________________________________ PRC No: _______________________________ Valid Until: _______________ _________________________ PNA No: _______________________________ Valid Until: _______________ _________________________ Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________ Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________ (Signature over printed name of Chief Nurse) (Signature over printed name of Dean) Date Signed: __________________________________________________________________________________ Date Signed: _______________________________________________________________________________ Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________ Degree: BSN, RN, PRC No: _______________________________ Valid Until: ____________________________________________ PRC No: ______________________________ Valid Until_______________________ _____________________ PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________ PNA No: ______________________________Valid Until: ______________________ _____________________ ADPCN No: Valid Until: ___________________________________________
- 5. NAME OF STUDENT:______________________________________________________________________________________________________________ First Course (if any): _______________________________________________ ____ __________________ Name and Address of School: Holy Trinity University ______________________________________________________________________________________ School Graduated From: __________________________________________ _________________________ Quezon St., Puerto Princesa City, Palawan _____________________________________________________________________________________________ Year of Admission in the Bachelor of Science in Nursing Program: _________ _________________________ Recognition and Accreditation Level: PAASCU Level 1 ____________________________________________________________________________________ Year Graduated (BSN Program):____________________________________ Date School/Program was recognized: June 10, 1991 _____________________________________________________________________________________ V. CORD DRESSING Gender of Signature of No. Case No. Date of Delivery Name of Baby Name and Age of Mother Name of Hospital Name of Qualified C.I. Baby Qualified C.I. 1. 2. 3. 4. 5. Supervised By:_________________________________________________________ ____________________ (Signature over printed name of Clinical Supervisor) Date Signed:____________________________________________________________ ____________________ Degree:BSN, RN, MAN _______________________________________________________________________ PRC No: _______________________________ Valid Until: _______________ _________________________ PNA No: _______________________________ Valid Until: _______________ _________________________ Noted by: AGNES B. PALAO, RN, MAN, Ph.D. __________________________________________ Noted By: _ MARIA CELINA G. CASIS, RN, MSN __________________________________ (Signature over printed name of Chief Nurse) (Signature over printed name of Dean) Date Signed: __________________________________________________________________________________ Date Signed: _______________________________________________________________________________ Degree:BSN, RN, MPA, Ph.D. ____________________________________________________________________ MSN _______________________________________________________________________ Degree: BSN, RN, PRC No: _______________________________ Valid Until: ____________________________________________ PRC No: ______________________________ Valid Until_______________________ _____________________ PNA No: 12564 __________________________ Valid Until: Lifetime Member___ ____________________________ PNA No: ______________________________Valid Until: ______________________ _____________________ ADPCN No: Valid Until: ___________________________________________