Controlled Drug Register (1-Page Table Format)
| CONTROLLED DRUG REGISTER (Issue / Return / Count) | |
| Hospital: ________________________ | Dept Anesthesia | Form Code: F-22 | Version: ___ | Effective: ___ | PAGE 1 of 1 |
| SECTION 1 — STORAGE LOCATION & SHIFT DETAILS | |
|
Area:
☐ OR
☐ PACU
☐ NORA
☐ Block Area Cabinet/ADC ID: ___________________________________ |
Date: ______/______/_________
Shift: ☐ AM ☐ PM ☐ Night Opening balance verified by (Name/Sign): __________________________________________________ |
| SECTION 2 — TRANSACTION LOG | |||||||||
| Time | Patient MRN / Case ID |
Drug Name + Strength |
Qty Issued (Amp/Vial) |
Dose Admin. |
Qty Returned |
Qty Wasted (F-22 link) |
Balance After |
User Name + ID + Signature |
Witness Signature (If required) |
| SECTION 3 — END-OF-SHIFT COUNT & RECONCILIATION |
|
Physical count completed:
☐ Yes
☐ No
Closing balance: ______________________
Discrepancy?
☐ No
☐ Yes
Amount: _________
Action taken: ____________________________________________________
Counted by (Name/Sign): __________________________________
Verified by (Name/Sign): __________________________________
Time: _________
|