Monthly Controlled Substance Inventory Log Page 4
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4Unit:
If a tag is broken for any reason, an entry must be made below with the reason.
Month/Year:
PAGE 9 OF 9
If a tag is changed without an entry below and/or the CS drugs are out-of-balance per policy 300-37, notify your EMS Coordinator immediately.
If the tag is broken daily for morning CS inventory then state that on the first line below to take care of daily inventory reporting for the month.
Date tag
Reason tag broken:
Amount
Amount
New Tag
Signature(s)
System #
Agency
Broken
Med Name (Exchanged/Used on run/etc)
Used
Wasted
Number
Run #
Daily
Morning Inventory Check
N/A
N/A
Changed Daily See Daily Log
See Daily Log N/A
TH
A COPY OF THE PCR SHALL ACCOMPANY THIS FORM TO THE SYSTEM BY THE 25
OF THE FOLLOWING MONTH
FOR EVERY CONTROLLED SUBSTANCE ADMINISTERED. PCR MUST SHOW USE/WASTE/WITNESS.
Attachment: Policy 300-37h
Revised 9/26/16
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