St Gemma'S Hospice Policies And Guidance Page 8
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19St Gemma’s Hospice
Non-Stock Medicines (excluding schedule 2 and 3 CDs and Oramorph 10mg/5ml)
RN locks patient specific non-stock medicines delivered from Lloyds in named patient’s
bedside medicines locker or in drugs fridge.
Stock Schedule 2 and 3 CDs (including temazepam) and Oramorph
10mg/5ml
RN plus one of the following - Ph, Lloyds technician or Dr enters stock CDs into the
current STOCK controlled drug register with the exception of temazepam and oramorph
10mg/5ml which are not entered in the register as it is not a legal requirement to do so but
entered into the separate book kept for the purpose of auditing there storage and
destruction.
The RN, Ph, Dr or technician adds their name signature and initials to the list at the
beginning of the CD register if not previously recorded for that particular CD register.
In STOCK controlled drug register RN, Ph, Dr or technician ensure a dedicated entry
page for each strength and form of each drug, that the index page is up to date and that
there is a page for expired stock and other CDs awaiting destruction by the Home Office
Authorised person.
RN, Ph, Dr or technician enter the following information in to the CD record book:
Date of receipt
Order reference number (for CDs from Chapel Allerton Hospital - CAH)
Quantity received i.e. number of tablets, ampoules, patches
Place received from i.e. “Stock from Lloyds” or “Stock from CAH”
Enter new stock balance and check it is correct including existing stock
Signature of both person making entry and witness.
Non-Stock/patient specific and discharge Schedule 2 and 3 CDs (including temazepam)
and Oramorph 10mg in 5ml
RN plus one of the following - Ph, Lloyds technician or Dr enters non-stock/patient
specific and discharge (TTO) CDs as outlined above into the current “PATIENT’S OWN”
controlled drug register with the exception of temazepam and oramorph 10mg/5ml which
are not entered in the register as it is not a legal requirement to do so but entered into the
separate book kept for the purpose of auditing there storage and destruction.
The RN, Ph, Dr or technician adds their name signature and initials to the list at the
beginning of the CD register if not previously recorded for that particular CD register.
RN, Ph, Dr or technician ensure “PATIENT’S OWN” controlled drug register has a
dedicated entry page for both Discharge CDs (TTOs) and “Patients own CDs not to be
used during current admission”. Entries are marked “IN” in the margin. A line is left
between these entries on both of these in order for the medication to be signed out when
returned to the patient or removed for destruction. This line is marked “OUT” in the
margin.
RN plus Ph, Dr or technician enters any patients own CDs which are being used in the
hospice (by that patient ONLY) into the Patients Own controlled drug register on a
separate page for each strength and form for that patient. Refer to “Policy for the Reuse of
Patient’s Own Drugs”.
RN, Ph, Dr or technician enter the following information in to the “PATIENT’S OWN”
CD record book:
Date of receipt
Quantity received i.e. number of tablets, ampoules etc
Person/place received from i.e. “TTO from Lloyds” or “Received from Patient”
Enter new stock balance and check it is correct (including existing patient
specific CDs already in register)
Signature of both person making entry and witness.
Page 8 of 19
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