Sem Med Box/a-Pack Supply Use/replacement Form

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SEM MED BOX/A-PACK SUPPLY USE/REPLACEMENT FORM
Version: 23 - February 2017
AGENCY/UNIT #:
HOSPITAL: __________________________DATE:_____________________
INCIDENT #:
EMS CREW (Names): _____________________________________
Patient Name
Patient DOB: ____________________________________________
:
MEDICATION
UNIT/SIZE
QNTY
USED
NOTE
MISCELLANEOUS
UNIT/SIZE
QNTY
USED
NOTE
Acetaminophen
Unit dose cup
1
Alcohol Pads
12
650 mg/20.3 mL
Incident Report Form*
A-Pack
1 Each
10 ml oral syringe in bag
Adenosine 6 mg/2 mL
Vial/Syringe 2
5
IV Additive Labels
3
mL
IV Tubing 60
2
Albuterol 2.5 mg/3 mL*
Vial – UD 3 mL
6
drops/mL
A-Pack
6
(Minidrip) with Y Site
Amiodarone
Amp/Vial
3
Pre-Pierced Reseal
150 mg/3 mL
Nebulizer*
A-Pack
1 Each
Aspirin 81 mg chewable
X 1 Bottle or
1
tablets*
4 UD Tabs
Blunt Cannula 18 g –
18 G x 1 inch
5
A-Pack
4
1 inch *
A-Pack
2
Atropine 1mg/10 mL
Syringe 10 mL
3
Filter Needle
18-21 G
3
Calcium Chloride
Syringe 10 mL
2
Intranasal Mucosal
A-Pack
1 Each
1 g/10 mL
Atomization Device*
Dextrose 50%
Syringe 50 mL
1
Red Lock*
A-Pack
1 Each
25 g/50 mL*
A-Pack
1
Replacement Form*
A-Pack
1
Diphenhydramine
Vial 1 mL
2
(Benadryl) 50 mg/1 mL
1mL
Syringe 1 mL
5
Syringe
(With
Epinephrine
Amp/Vial 1 mL
2
)
needle/Luer Lock
1 mg/1 mL
Epinephrine
Syringe 10 mL
7
Syringe 10 mL
Syringe 10 mL
5
1 mg/10 mL
Syringe 20 mL
Syringe 20 mL
1
Ipratropium Bromide
2.5 mL Vial – UD
2
0.02% (In Baggie)*
A-Pack
1
Needle
18 G x 1.5 inch
3
Lidocaine 100 mg/5 mL
Syringe 5 mL
3
3 or 4-Way Stopcock*
1 Each
Lidocaine Jelly 2%
Tube 5 mL/30 mL
1
Syringe w/ needle
Syringe 3 mL
5
3 mL– 21/22 G x 1.5
A-Pack
2
Magnesium Sulfate
Amp/Vial
4
inch*
1 g/2 mL
Methylprednisolone
Vial
1
Ordering Physician/Hospital: _________________________________
125 mg
Naloxone*
2 x 2 mL Syringe
Replacing Hospital: _________________________________________
2 mg/2 mL or
or
2
0.4 mg/mL
1 x 10 mL Vial
(A-Pack)
Total = 4 mg
1
Receiving Physician Signature: _______________________________
Nitroglycerin*
Bottle
1
(Controlled Substance use only)
0.4 mg/tab
A-Pack
1
Ondansetron
2 mL vial
2
Receiving Physician Printed Name: ____________________________
2 mg/mL*
(Controlled Substance use only)
Prednisone 50 mg tab*
50 mg. tab
1
A-Pack
1
Racepinephrine 2.25%
0.5 mLVial
1
Date: _____________________________________________________
11.25 mg/0.5 mL
PARAMEDIC’S STATEMENT
Sodium Bicarbonate
Syringe 50 mL
2
SEM EMS Medication Box number ________ has been opened and the
50 mEq/50 mL
above noted medication(s) used as prescribed. I accept pharmacy sealed
Sodium Chloride 0.9%
Vial 20-30 mL or
1
SEM EMS Medication Box Number _________ sealed with breakaway
(Preservative free)
10mL syringe
tag number ____________
Sodium Chloride 0.9%
Bag 50 mL
1
Paramedic Signature: _________________________ Date: _________
CONTROLLED
UNIT/SIZE
QTY/
DOSE
DOSE
DOSE
GIVEN
WASTED
SUBSTANCES
REPLACING PHARMACIST’S STATEMENT
The medications in the sealed SEM EMS Medication
Fentanyl 50 mcg/ mL
Vial/Amp 2 mL
3
Box number _______ have been distributed according to the
Medication/Use and Replacement Policy of the participating Medical
Midazolam 5 mg/1 mL
Vial 1 mL
4
Control Authority. All medications are in the correct concentration,
Morphine 10 mg/1 mL
Vial/Amp 1 mL
2
dosage form, volume, amount, and not expired.
Name of Pharmacist on the Seal: ________________________________
Documentation of Controlled Substance Waste (Please Print)
Signature of Replacing Pharmacist: ___________________________
Witness: ____________________Medic:________________________
Date: _____________Hospital: ________________________________
Needleless stock only!
* Items in both Medication Box and A-Pack

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