Narco c Medica on Inventory /

Client: _______________________________

Drug: _______________________________
Administra on Record
Use this form for each individually prescribed
Dose: ______________________________ narco c medica on. Record each administra on of narco c
medica on on this form as well as eMar. At every shi change, verify
Rx#: ______________________________ the quan ty of narco c medica on and check it against the “pa ent
inventory” in KIPU EMR.
Provider: _______________________________
Instruc ons: One sta member (on shi ) will count the medica on in the
lockbox, and another sta member (at the end of the shi ) will check the
(PHARMACY STICKER) “pa ent inventory” number in the KIPU. If there are no discrepancies, both
sta members will ini alize or sign the document.

NARCOTIC MEDICATION ADMINISTRATION RECORD SHIFT CHANGE COUNT

Qty on Qty Qty
Date Time Name of Sta Giving Sta Signature Sta Ini als Time
Hand Given Remaining
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STAFF SIGNATURES
Ini als Printed Name Signature Ini als Printed Name Signature
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 NARCOTIC MEDICATION ADMINISTRATION RECORD SHIFT CHANGE COUNT
Qty on Qty Qty
Date Time Name of Sta Giving Sta Signature Sta Ini als Time
Hand Given Remaining
/
/
/
/
/
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COMPLETE AT TIME OF DISCHARGE OR MEDICATION DISCONTINUATION

FINAL MEDICATION COUNT: ____________ DATE: ___________ STAFF FULL NAME: ________________________
☐MEDICATION PLACED IN MEDICATION DESTRUCTION BOX
☐ MEDICATION LOGGED IN MEDICATION DESTRUCTION RECORD (DHCS 5078 FORM)
☐ ENTIRETY OF MEDICATION APPROVED TO BE DISCHARGED WITH CLIENT
☐ A QUANTITY OF _________________ APPROVED TO BE DISCHARGED WITH CLIENT
☐ FORM UPLOADED TO PATIENT CHART IN KIPU UNDER "UPLOADED DOCS" BY: ________________( STAFF INITIALS)
(Retain records for 3 years)
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