Controlled Drug Administration Record
Use this form to document controlled-drug administration events, dose details, timing, counts, waste, discrepancies, and staff verification.
Patient / Resident Information
Patient / Resident Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Ward / Unit / Care Location
*
Please Select
Ward A
Ward B
Ward C
ICU
Emergency
Long-term Care
Other
Medical Record / Chart Number
Medication and Order Details
Medication Name
*
Strength / Concentration
*
Dosage Form
*
Tablet
Capsule
Liquid
Injection
Patch
Sublingual
Other
Scheduled Dose
*
Prescribed Route of Administration
*
Oral
IM
IV
Sublingual
Transdermal
Other
Prescribed Frequency / Schedule
*
Prescriber Name
*
Order Start / End Date
-
Month
-
Day
Year
Date
Administration Event
Scheduled Administration Date/Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Actual Administration Date/Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Dose Administered (with units)
*
Administration Status
*
Please Select
Administered
Withheld
Refused
Omitted
Returned to Stock
Partial Dose
Route Used
*
Please Select
Oral
Sublingual
Buccal
Injection
Intravenous
Intramuscular
Subcutaneous
Rectal
Topical
Inhalation
Other
Administration Site
Reason for Withholding, Refusal, or Omission
Immediate Patient Response or Observation Notes
Controlled Drug Count / Waste / Variance
Previous Count on Hand
*
Quantity Administered
*
Quantity Wasted
Quantity Remaining After Administration
*
Witness / Second Check Required?
*
Yes
No
Witness Name
Variance or Discrepancy Noted?
*
Yes
No
Discrepancy / Incident Details
Follow-up Action Taken
Administrator Verification
Administrator Full Name
*
First Name
Last Name
Role / Title
*
Please Select
Nurse
Pharmacist
Physician
Certified Nursing Assistant
Medication Aide
Other
Signature
*
Date and Time Signed
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit Record
Submit Record
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