INDEX PAGE #1 of 3. Page # Resident's Name Name of Drug Page # Resident's Name Name of Drug

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2 INDEX PAGE #1 of 3 Page # Resident's Name Name of Drug Page # Resident's Name Name of Drug

3 INDEX PAGE #2 of 3 Page # Resident's Name Name of Drug Page # Resident's Name Name of Drug

4 INDEX PAGE #3 of 3 Page # Resident's Name Name of Drug Page # Resident's Name Name of Drug

5 Controlled Drug Record Book 2 (Green Cover) Copyright by MAXnJAX Media. All Rights Reserved. Except as permitted under the US Copyright Act of 1976, no part of this publication may be reproduced, distributed, or transmitted in any form or by any means or stored in a database or retrieval system without the prior written permission of the Author. Printed in the Unites States of America First Printing: March 2014 ISBN: This publication is designed to provide accurate and relative information in regard to the subject matter covered. It is designed to be generic in its use and application. All users must understand and apply the applicable policies, procedures, laws, statutes, regulations, and all other requirements regarding the subject matter hereof. It is sold as is with the understanding that neither the author nor the publisher is engaged in rendering medical, legal, or other professional services. If medical or legal advice or other expert assistance is required, the services of a competent professional person should be sought. A production of: MAXnJAX Media & BLAST Information Systems For more information please visit: MAXnJAX.com/drugbook - Order Copies - us at: info@maxnjax.com amazon.com, using the ISBN number above (visit our web site for special offers) Need a specific form or layout? Want a customized look or color scheme? Want to include your company name, logo, pictures, graphics, etc.? Send an with your request and we will work with you to provide an affordable option to meet your individual needs.

6 - RECORD BOOK STATUS - Book Location (i.e. station, cart, etc.) Book Identifier / Number / Code (i.e. use a distinctive identifier, number, code, etc.) Book Start Date / / Transferred From Book: Book End Date / / Transferred To Book:

7 - OTHER INFORMATION - Issued To: Signature: Date: Issued By: Date: Phone #: Cell #: (s): Other: Company / Group: Department: Address 1: Address 2: City: State: Zip: Other: Notes:

8 SHIFT COUNT CONTROLLED DRUGS / MEDS (including all controlled drugs / meds in the emergency box) Today's Time Signature of Nurse Signature of Nurse Count Correct? Date Of Day Going Off Duty Coming On Duty Yes No At each shift change, all controlled drugs / meds must be counted. Complete an incident report to document any discrepancies.

9 SHIFT COUNT CONTROLLED DRUGS / MEDS (including all controlled drugs / meds in the emergency box) Today's Time Signature of Nurse Signature of Nurse Count Correct? Date Of Day Going Off Duty Coming On Duty Yes No At each shift change, all controlled drugs / meds must be counted. Complete an incident report to document any discrepancies.

10 SHIFT COUNT CONTROLLED DRUGS / MEDS (including all controlled drugs / meds in the emergency box) Today's Time Signature of Nurse Signature of Nurse Count Correct? Date Of Day Going Off Duty Coming On Duty Yes No At each shift change, all controlled drugs / meds must be counted. Complete an incident report to document any discrepancies.

11 EMERGENCY DRUG / MED SUPPLY This page is specifically to be used with all controlled drugs / meds in the emergency box. Drug / Med Name: Page No: 1 Drug / Med Given Present In From Resident's Prescriber's Nurse's Date Time Dose Balance Pharmacy Name Name Signature Two nurses must witness and sign the destruction / waste of any controlled drugs / meds. When folding pages over, the disposition of drugs / meds must be documented appropriately.

12 CONTROLLED DRUG / MED DISPOSITION The applicable box below must be completed when this page is folded over. TRANSFER TO NEW PAGE TRANSFER TO DIFFERENT LOCATION New location transferred to: Nurse receiving transfer: SURRENDER TO PERSON Remaining quantity being surrendered: Nurse making surrender: Person Surrendered To Printed Name: Signature: - Resident / Responsible Party / Nurse / Administrator - (circle one) DEPLETION OF DRUG / MED NONE REMAINING PAGE FINISHED Date completed: Nurse completing:

13 EMERGENCY DRUG / MED SUPPLY This page is specifically to be used with all controlled drugs / meds in the emergency box. Drug / Med Name: Page No: 9 Drug / Med Given Present In From Resident's Prescriber's Nurse's Date Time Dose Balance Pharmacy Name Name Signature Two nurses must witness and sign the destruction / waste of any controlled drugs / meds. When folding pages over, the disposition of drugs / meds must be documented appropriately.

14 CONTROLLED DRUG / MED DISPOSITION The applicable box below must be completed when this page is folded over. TRANSFER TO NEW PAGE TRANSFER TO DIFFERENT LOCATION New location transferred to: Nurse receiving transfer: SURRENDER TO PERSON Remaining quantity being surrendered: Nurse making surrender: Person Surrendered To Printed Name: Signature: - Resident / Responsible Party / Nurse / Administrator - (circle one) DEPLETION OF DRUG / MED NONE REMAINING PAGE FINISHED Date completed: Nurse completing:

15 EMERGENCY DRUG / MED SUPPLY This page is specifically to be used with all controlled drugs / meds in the emergency box. Drug / Med Name: Page No: 10 Drug / Med Given Present In From Resident's Prescriber's Nurse's Date Time Dose Balance Pharmacy Name Name Signature Two nurses must witness and sign the destruction / waste of any controlled drugs / meds. When folding pages over, the disposition of drugs / meds must be documented appropriately.

16 CONTROLLED DRUG / MED DISPOSITION The applicable box below must be completed when this page is folded over. TRANSFER TO NEW PAGE TRANSFER TO DIFFERENT LOCATION New location transferred to: Nurse receiving transfer: SURRENDER TO PERSON Remaining quantity being surrendered: Nurse making surrender: Person Surrendered To Printed Name: Signature: - Resident / Responsible Party / Nurse / Administrator - (circle one) DEPLETION OF DRUG / MED NONE REMAINING PAGE FINISHED Date completed: Nurse completing:

17 ADMINISTRATION RECORD CONTROLLED DRUGS / MEDS Date: Rx #: Rx #: Page No: 11 Page Start Date: Transfer From Book: Page: By Nurse: Resident's Name: Prescriber's Name: Directions: Drug / Med Name: Pharmacy Name: Balance (BAL) Forward: Balance (BAL) Forward: Drug / Med Given New In From Nurse's Drug / Med Given New In From Nurse's Date Time Dose BAL Pharm Signature Date Time Dose BAL Pharm Signature Two nurses must witness and sign the destruction / waste of any controlled drugs / meds. When folding pages over, the disposition of drugs / meds must be documented appropriately.

18 CONTROLLED DRUG / MED DISPOSITION The applicable box below must be completed when this page is folded over. TRANSFER TO NEW PAGE TRANSFER TO DIFFERENT LOCATION New location transferred to: Nurse receiving transfer: SURRENDER TO PERSON Remaining quantity being surrendered: Nurse making surrender: Person Surrendered To Printed Name: Signature: - Resident / Responsible Party / Nurse / Administrator - (circle one) DEPLETION OF DRUG / MED NONE REMAINING PAGE FINISHED Date completed: Nurse completing:

19 ADMINISTRATION RECORD CONTROLLED DRUGS / MEDS Date: Rx #: Rx #: Page No: 149 Page Start Date: Transfer From Book: Page: By Nurse: Resident's Name: Drug / Med Name: Prescriber's Name: Pharmacy Name: Directions: Balance (BAL) Forward: Balance (BAL) Forward: Drug / Med Given New In From Nurse's Drug / Med Given New In From Nurse's Date Time Dose BAL Pharm Signature Date Time Dose BAL Pharm Signature Two nurses must witness and sign the destruction / waste of any controlled drugs / meds. When folding pages over, the disposition of drugs / meds must be documented appropriately.

20 CONTROLLED DRUG / MED DISPOSITION The applicable box below must be completed when this page is folded over. TRANSFER TO NEW PAGE TRANSFER TO DIFFERENT LOCATION New location transferred to: Nurse receiving transfer: SURRENDER TO PERSON Remaining quantity being surrendered: Nurse making surrender: Person Surrendered To Printed Name: Signature: - Resident / Responsible Party / Nurse / Administrator - (circle one) DEPLETION OF DRUG / MED NONE REMAINING PAGE FINISHED Date completed: Nurse completing:

21 ADMINISTRATION RECORD CONTROLLED DRUGS / MEDS Date: Rx #: Rx #: Page No: 150 Page Start Date: Transfer From Book: Page: By Nurse: Resident's Name: Prescriber's Name: Directions: Drug / Med Name: Pharmacy Name: Balance (BAL) Forward: Balance (BAL) Forward: Drug / Med Given New In From Nurse's Drug / Med Given New In From Nurse's Date Time Dose BAL Pharm Signature Date Time Dose BAL Pharm Signature Two nurses must witness and sign the destruction / waste of any controlled drugs / meds. When folding pages over, the disposition of drugs / meds must be documented appropriately.

22 CONTROLLED DRUG / MED DISPOSITION The applicable box below must be completed when this page is folded over. TRANSFER TO NEW PAGE TRANSFER TO DIFFERENT LOCATION New location transferred to: Nurse receiving transfer: SURRENDER TO PERSON Remaining quantity being surrendered: Nurse making surrender: Person Surrendered To Printed Name: Signature: - Resident / Responsible Party / Nurse / Administrator - (circle one) DEPLETION OF DRUG / MED NONE REMAINING PAGE FINISHED Date completed: Nurse completing:

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