Daily Controlled Drug And Key Inventory Form Page 3

DEPARTMENT OF HEALTH SERVICES

COUNTY OF LOS ANGELES

SUBJECT:

MONTHLY DRUG STORAGE INSPECTION FORM

REFERENCE NO. 702.2

Provider Agency: ___________________________________

ALS Unit: _________________

Date/Time Monthly Drug Storage Inspection Form conducted: ____________________________

Verify the following items:

YES

1. Controlled substances are adequately locked and secured.

2. Expiration dates were verified.

Indicate any expired medications: ____________________________________

3. Controlled substance physical inventory count matches documentation.

4. All forms are complete and legible including:

a. RN printed name and signatures and clearly displayed.

b. Paramedic signatures and license numbers clearly displayed.

c. Name of drug and amount wasted clearly noted.

Other Findings:

Recommendations:

Actions Taken:

Comments:

INSPECTOR’S NAME/TITLE:

INSPECTOR’S SIGNATURE

Reviewed 4-1-14

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Parent category: Business