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Schedule II Controlled Substance Procedures for Community Pharmacies (7.14)

Schedule II Controlled Substance Procedures for Community Pharmacies (7.14) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.14





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 1
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

I. Purpose: To establish a safe, reliable and uniform method of ordering, storing, dispensing, returning,
and wasting of Drug Enforcement Agency (DEA) schedule II controlled substance medications (C-II
medications) in all UW Health community pharmacies. To be compliant with federal and state laws
governing controlled substances. To describe systems in place for identifying and preventing possible
controlled substance diversion.

II. Policy:
A. All use of C-II medications in UW Health community pharmacies will follow the procedures
outlined below.
B. UW Health will maintain adequate systems to minimize risk for diversion of C-II medications.
C. UW Health will have systems to detect diversion of C-II medications in a timely manner.
D. UW Health will have systems to ensure staff that order, dispense and in other ways handle C-II
medications in community pharmacies comply with all aspects of this procedure and in
compliance with all state and federal laws and regulations.
E. UW Health will have training systems that ensure staff has a thorough understanding of policies
and procedures related to use of C-II medications.
F. UW Health will have systems to investigate, resolve and if necessary report any suspected
diversion of C-II medications.

III. Forms
A. Schedule II Narcotic Tracking Log (Appendix A) – This form is used to document all C-II medication
transactions and serves as the official record for the legally required perpetual inventory log. This
official form is maintained on UConnect in the pharmacy workgroup folder in the following
location:
Ambulatory – Ambulatory Forms

B. Controlled Substance Discrepancy Form (Appendix B) – This form is used to document C-II
medication discrepancies as outlined in Pharmacy Policy 7.4.

C. DEA Form 222 (Appendix C) – This three ply form is used to place orders for C-II medications by
one DEA registered entity to another DEA registered entity.

D. CSOS Receiving Documentation (Appendix D) – This form is used to document receipt of C-II
medications in lieu of the blue copy of DEA form 222.






Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 2
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

IV. Procedure:
A. General
1. Each UW Health community pharmacy shall maintain, on a current basis, a complete and
accurate written perpetual inventory record for the receipt and disposition of all C-II
medications
2. All records (prescriptions, DEA Form 222s, CSOS Receiving documents, Perpetual Inventory
Logs, and Discrepancy Reports) will be kept for a ten year period.
3. C-II medication records shall be maintained separate from all other records.
a. All controlled medication prescriptions that are received electronically will be
retrievable from the pharmacy dispensing software system
4. Community pharmacies will only acquire C-II medications from a commercial vendor through
legal DEA ordering processes, and cannot take possession of medications from patients or
other parties who wish to return or dispose of C-II medications.

B. Storage of Controlled Substances
1. Dedicated, locked storage cabinets are used to secure C-II medications in community
pharmacies.
2. Storage cabinets will be locked or under constant supervision with access limited only to
authorized personnel.
3. Refrigerated C-II medications may be dispersed with other refrigerated medications in the
pharmacy.

C. Ordering of C-II Medications and Records of Receipt.
1. Orders of C-II medications will be completed through the use of a DEA Order Form 222 signed
by an individual with power of attorney to sign controlled substance order forms.
2. Receipt of C-II medications from vendors will be documented on the DEA Form 222.
a. A pharmacy employee will record the quantities and dates items were received on the
blue copy of DEA Form 222 as required by law.
b. It is the responsibility of the initialing pharmacist to verify the amount stated on the
CSOS form for each C-II medication matches the amount actually received.
c. This document shall be filed separately from other receiving documentation and will be
available for review by the DEA and UW Health audit personnel.
d. The pharmacist who completes the documentation on the DEA Form 222 will initial the
upper right hand corner of the DEA Form 222.
e. A pharmacist will verify the accuracy and completeness of the recording of receipt
documentation on the DEA Form 222 and corresponding entries in the perpetual
inventory logs and initial the DEA Form 222 in the upper right hand corner to document
this verification.





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 3
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

f. Where a pharmacist is staffing alone at the time of C-II medication receiving, the DEA
Form 222 shall be tagged for verification by a different employee (pharmacist or
technician) on the day a different employee works.
3. Controlled Substance Ordering System (CSOS) may be used instead of DEA Form 222.
a. A pharmacy employee will record the quantities and dates items were received on the
copy of the CSOS purchase order in lieu of the blue copy of DEA Form 222.
b. This document shall be filed separately from other receiving documentation and will be
available for review by the DEA and UW Health audit personnel.
c. The pharmacist who completes the documentation on the CSOS purchase order form
will sign under the receiving documentation on the CSOS purchase order.
d. It is the responsibility of the signing pharmacist to verify the amount stated on the
CSOS form for each C-II medication matches the amount actually received.
e. A pharmacist will verify the accuracy and completeness of the recording on the CSOS
purchase order and corresponding entries in the perpetual inventory logs and initial
the CSOS Purchase order alongside the pharmacist’s signature.
f. Where a pharmacist is staffing alone at the time of C-II medication receiving, the CSOS
purchase order shall be tagged for verification by a different employee (pharmacist or
technician) on the next day a different employee works.
g. For all CSOS orders a staff member will complete the receiving in McKesson Connect
and save a copy of the final CSOS pdf document in the J:\rx\rxshare\CSOS Archive
folder.
4. Perpetual Inventory Log Documentation
a. Each C-II medication received on a business day shall be added to stock and
documented in the perpetual inventory with the following information:
i. The words “Add-To-Stock”
ii. The CSOS number associated with the addition
iii. The quantity added to inventory
iv. The new total quantity in inventory
v. Two staff initials
ξ The same staff members who sign the DEA Form 222 or CSOS purchase order
will also initial each corresponding entry to the perpetual inventory logs.
ξ Each set of initials is responsible for verifying that:
o Quantity added to inventory matches quantity received as listed on the
CSOS purchase order for DEA Form 222
o New total quantity documented in perpetual inventory matches actual
inventory on hand
ξ Where a pharmacist is staffing alone at the time of C-II medication receiving,
each “Add-To-Stock” perpetual inventory log entry shall be tagged for
verification by a different employee (pharmacist or technician) on the next day
a different employee works. This employee will serve as the second initials for





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 4
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

the perpetual inventory log entry and is responsible for locating the DEA Form
222 or CSOS order form and that appropriate documentation is present as
stated in C-2-b and that correct documentation exists on the perpetual
inventory log as stated in C-3.
5. Shipping Errors
a. If vendor makes an error in shipping product (wrong product, amount, dosage form,
etc…) a perpetual inventory entry is required for receipt of product.
b. Note on CSOS order form or DEA Form 222 the description of wrong item received, the
date and quantity (not on order line, but in separate area of form).
c. When item is returned to vendor, transaction must be handled as a transfer (see E
below).

D. Inventory
1. A physical inventory of all C-II medication shall be taken monthly. This can be performed in
any manner which inventories all C-II controlled substances at least once monthly. For
example weekly inventories of 25% of all C-II medication so that over 4 weeks 100% of all C-II
medications are inventoried.
a. Each inventory shall be documented in the perpetual inventory with the following
information:
i. The word “AUDIT”
ii. Date of inventory
iii. Initials of staff performing inventory
ξ Inventory audits do not require two initials and can be performed by pharmacy
students under a pharmacists’ direction, with the understanding that the
student’s preceptor is ultimately responsible for any discrepancies.
iv. The audit will include verification of the following
ξ Quantity on hand matches the expected inventory on the perpetual inventory
record.
ξ All documented transactions for each drug since the last routine audit is
verified as having 2 initials.
ξ If a second set of initials is missing, a pharmacy manager must be notified
immediately to reconcile this discrepancy. In addition, the person performing
the inventory will complete the steps required of the second initials
(verification of prescription, CSOS or DEA Form 222 entry, or verification of any
other transaction that should have been performed as outlined in this policy)
and note in the margin of the log that this verification was performed and date
completed.
v. At the time of the audit, a comparison with the Enterprise physical inventory level
will also be performed.





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 5
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

ξ Investigation of discrepancies between the two systems will be performed with
corrections to the enterprise counts completed when needed.

E. Records of Transfer
1. A DEA Form 222 shall be completed for all transfers from the community pharmacy to
another DEA registered entity as mandated by the Federal Controlled Substances Act
a. This includes transfers of any C-II medication between community pharmacies or
transfers to distributors or vendors.
b. The form must be filled out completely with no material alterations or erasures and
signed by individual with legal power of attorney to sign DEA Form 222.
c. The transferring pharmacy will receive the brown and green copies of the form and will
be completed with the following by a pharmacist on both brown and green copies of
the DEA Form 222.
i. The transferring pharmacy’s DEA will be recorded in the section of the form labeled
“Suppliers DEA Registration Number”.
ii. The packages shipped and date shipped completed in appropriate lines of the
form.
iii. The pharmacist who completes the form will also initial in the top right hand corner
of the form
iv. The brown copy will be kept on file in the pharmacy.
v. The green copy of the form will be sent to the DEA.

2. Perpetual Inventory Log Documentation
a. Each C-II medication transferred to another DEA registered entity must be documented
in the perpetual inventory log with the following information:
i. The word “Transfer”
ii. DEA registered entity transferred to
iii. Quantity of C-II medication transferred
iv. Quantity remaining in inventory
v. Quantity removed from inventory as noted in the log matches the quantity
intended to be transferred as noted on the DEA Form 222.
vi. Quantity remaining on hand matches expected quantity in perpetual inventory log.
vii. The DEA Form 222 has been filled out completely
viii. Where a pharmacist is staffing alone at the time of C-II medication transfer, each
“Transfer” perpetual inventory log entry shall be tagged for verification by a
different employee (pharmacist or technician) on the next day a different
employee works. This employee will serve as the second initials for the perpetual
inventory log entry and is responsible for locating the DEA Form 222 or CSOS order
form and that appropriate documentation is present as stated in E-1 and that
correct documentation exists on the perpetual inventory log as stated in E-2.





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 6
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies


F. Profiling for Prescriptions that are on hold for future dispensing
1. All pharmacies will maintain a C-II medication profile storage box. When hard copy C-II
prescriptions are received, the following will be completed:
a. A pharmacy staff member will initial and note the date that the prescription was
received on the face of the prescription.
b. The hard-copy prescription will be scanned into the Enterprise computer system
c. Upon dispensing, the hard prescription copy must be pulled from the storage box
above
d. When a pharmacist does the final check of the prescription, they will also initial the
face of the prescription.
2. When electronic C-II prescriptions are received, the prescription does NOT need to be
printed or stored in the profile storage box.

G. Prescription Filling and Dispensing
1. Hard-Copy Prescription Receipt
a. A pharmacy staff member will initial and note the date that the prescription was
received on the face of the prescription.
b. The hard-copy prescription will be scanned into the pharmacy dispensing software
system.
c. When a pharmacist does the final product check of the prescription, they will also
initial the face of the prescription.
2. Electronic Prescription Receipt
a. A hard copy of the prescription is not needed if the medication is received
electronically
b. All electronic controlled substance prescriptions will be automatically be stored and
filed within the pharmacy dispensing software system. No dual initial and date on the
face of the prescription is needed.
3. Prescription Dispensing and Verification Documentation
a. All entries for patient dispensing shall be noted in the perpetual inventory log with the
Enterprise-created label (see appendix A) Manual entries are strictly prohibited.
b. Each entry shall be initialed by two staff members, one of which must be a pharmacist.
By initialing the pharmacy staff are verifying:
i. That the quantity filled in the prescription bottle matches the prescribed quantity
on the label affixed to the log, the entry of amount dispensed hand written in the
log, and matches the amount prescribed by the prescriber.
ii. The quantity remaining on hand in the inventory matches the expected inventory
as noted on the log.
iii. For hard copy prescriptions, the initialing staff are also verifying:





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 7
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

ξ Authenticity of the original hard copy and that initials and date of fill are
documented on face of prescription.
ξ That two people have signed the hard copy prescription.
c. For instances where a pharmacist is staffing alone at the time of C-II medication filling,
each perpetual inventory log entry shall be tagged for verification by a different
employee (pharmacist or technician) on the next day a different employee works. This
employee will serve as the second initials for the perpetual inventory log entry and is
responsible for verifying the elements defined in 2-b above.
4. Partial Prescription Filling
a. Federal Law limits partial filling of C-II medication to situations where the pharmacist is
unable to supply the full quantity called for in the written prescription.
b. In situations where a partial fill is required for a C-II that is received as an e-
prescription, the prescription image needs to be printed as a hard copy to proceed.
c. The pharmacist may supply a portion of the quantity requested provided a notation is
made of the quantity filled on the face of the written prescription order. The remaining
portion may be dispensed within 72 hours of the first partial dispensing. If the
remaining portion is not or cannot be dispensed with the 72 hour period, the
pharmacist must so notify the prescriber.
d. If the pharmacy does not have sufficient quantities of C-II medication to completely fill
the prescription, the following will occur:
i. First Component of Partial Fill
ξ The original Enterprise-created label will be affixed to the perpetual inventory
log.
ξ The dispense quantity on the label will be lined through, and the amount on
hand that will be dispensed will be hand written onto the label.
ξ Two staff members will initial this change on the label in addition to the initials
on the log records.
ii. Fill of remaining partial quantity
ξ When the remaining amount of medication is available to complete filling of
the prescription, a second Enterprise-created label will be generated, and
affixed to the perpetual inventory log.
ξ The quantity on the label will be lined through and the amount dispensed to
complete the original filling will be written onto the label.
ξ Two staff members will initial this change on the label in addition to the initials
on the log records. During this verification both the technician and the
pharmacist will verify that the amount dispensed is equal to or less than the
prescription amount less the initial fill amount.

5. Medication Adherence Packaging





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 8
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

a. The quantity of a C-II prescription that is being provided in adherence packaging must
be written and dispensed for a quantity that matches the number of days being
provided to the patient.
i. For example, if the patient has medication adherence packaging provided every 2
weeks, the C-II prescription must be written for a two week supply.
b. If the prescription is written for a quantity greater than the amount being dispensed,
the balance must be canceled and the prescriber should be notified.

H. Every week a pharmacy staff member will utilize the return to stock report in Enterprise to review
C-II medication prescriptions filled but not yet sold.
1. Review for Dispensed but not Sold C-II Medication Prescriptions
a. Each medication on this report shall be verified for its presence in the will-call area.
b. Any medications that are beyond 10 days from the date of filling shall be returned to
stock as outlined below.
c. Any medications that are missing shall be immediately investigated and resolved.

I. Records of Prescriptions Returned to Stock
1. When a prescription is returned to stock after being filled, appropriate notation is made in
the Enterprise system showing that the dispensed medication was returned to stock.
2. Perpetual Inventory Log Documentation
a. All prescription returns shall be noted with the following information in the perpetual
inventory log:
i. The words “Return-To-Stock” and the number of the original prescription number
for reference
ii. Quantity returned to stock
iii. Updated expected inventory
iv. Each entry shall be initialed by two staff members, one of which must be a
pharmacist. By initialing the transfer entry, staff member is verifying that:
ξ The quantity returned matches quantity filled
ξ The quantity remaining on hand in the inventory matches the expected
inventory on the log
J. Expired C-II Medication
1. Expired C-II medication must be returned to a reverse distributor (such as Capital Returns)
after receipt of a DEA Form 222 for the expired medications.
a. Processing of the DEA Form 222 is outlined in section E above.

K. Disposal of Contaminated or Damaged C-II Medication.
1. Contaminated or damaged C-II medication may be destroyed by a registered pharmacist and
this waste must be witnessed by a second registered pharmacist.





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 9
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

2. Documentation of the destruction with witness must be recorded on a discrepancy report
(appendix B).
a. The white copy of the report is then forwarded to the Manager of Asset Management
and Budget pharmacy department (see Pharmacy Policy 7.4 – Controlled Substance
Discrepancy Reporting).
b. The yellow copy of the report will be kept on file in the pharmacy.
c. Discrepancy reports will be reviewed by the Manager of Asset Management and
Budget and any follow up required documented on the discrepancy report.
d. Completed discrepancy reports will be kept in long term storage for 5 years (see
Pharmacy Policy 1.23 – Pharmacy Records Retention).
3. Perpetual Inventory Log Documentation
a. All destruction of contaminated or damaged C-II medication shall be noted with the
following information in the perpetual inventory log:
i. The words “Wasted – See Discrepancy Report”
ii. Quantity wasted
iii. Updated expected inventory
b. Each entry shall be initialed by two staff members, one of which must be a pharmacist.
By initialing the transfer entry, staff member is verifying that:
i. The quantity wasted matches quantity noted on discrepancy report
ii. The quantity remaining on hand in the inventory matches the expected inventory
on the log

L. Discrepancy Documentation
1. A pharmacy discrepancy report form (appendix B) shall be completed for all extra or missing
controlled substances. The report must outline the circumstances of the discrepancy
including individual’s involved and potential cause of discrepancy if possible (see Pharmacy
Policy 7.4 – Controlled Substance Discrepancy Reporting).
a. The discrepancy report will be completed by the end of the shift of the day the
discrepancy is discovered.
b. For significant quantities of extra or missing items (including situations where theft is
suspected) the individual who discovers the situation will notify their manager
immediately.
c. White copies of the discrepancy forms will be sent to the UW HEALTH Pharmacy Office
(mail code 1530) addressed to the attention of the Pharmacy Manager of Asset
Management and Budget.
d. Yellow copies of the discrepancy forms will be maintained on file in the community
pharmacy with other narcotic documents.
e. Discrepancy reports will be reviewed by the Pharmacy Manager of Asset Management
and Budget.
i. If warranted, losses will be reported to appropriate federal and local authorities.





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 10
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

2. Documentation of the discrepancy on the Schedule II Narcotic Tracking Log will be done
upon discovery of the discrepancy and will take the following form
a. The entry will be hand written stating “Correction – see discrepancy report” and also
include the date the correction was made.
b. The amount will be the quantity of the discrepancy either positive or negative.
c. The new balance will be the sum of the previous balance on the log and the amount of
the discrepancy.
d. Two staff members including one pharmacist will initial the entry verifying the
completion of the discrepancy report and the accuracy of the entry and final balance.




Example – Schedule II Narcotic Tracking Log Entry for Documentation of Discrepancy


M. Corrections to the Schedule II Narcotic Tracking Log
1. Any corrections to the Schedule II Narcotic Tracking Log will be completed as follows
a. Line through the item being corrected
b. Clearly write the corrected entry on the log and date
c. Two signatures will accompany each correction one of which must be a pharmacist.

Example – Corrections to Schedule II Narcotic Tracking Log





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 11
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies




N. Suspected Theft or Diversion
1. Any staff member who suspects that a theft or diversion of C-II medication has occurred
must report the circumstances of the events to an appropriate pharmacy manager for their
area immediately.
2. The manager will implement the process outlined in Appendix E when theft or diversion is
suspected.

O. Inadvertent possession
1. Any staff member who inadvertently removes C-II medication from inventories and takes
outside of UW Health should return the medication to UW Health immediately upon
discovery and report the circumstances to the community pharmacy manager or supervisor
for their area.
2. The community pharmacy manager or supervisor will complete a discrepancy report and
forward both report and medications to Pharmacy Manager of Asset Management and
Budget.
3. Medication will not be used for care of patients and may be saved for follow up investigation
if necessary.
4. Retail Pharmacy Manager will work with Employee and Labor Relations (ELR) to determine if
any disciplinary actions are appropriate.

P. Auditing and Surveillance
1. On a regular basis, audits will be conducted and trended to verify compliance with this policy
and to identify potential diversion.
2. Actual audits will be maintained in a separate document and will not be generally available
to most users of this policy.
3. Reports will be routinely provided to pharmacy and UW Health senior leadership to confirm
compliance with system control expectations.





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 12
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies


Q. Documentation of Expired Medications Returned to Reverse Distributer.
1. When a schedule II medication has expired and needs to be sent to a reverse distributer
(such as EXP) an entry is made in the log as follows:
a. The entry will be hand written stating “Drug Expired – See Expired Medication Log” and
also include the date the entry was made.
b. The amount will be the quantity of the expiring product as a negative value.
c. The new balance will be the sum of the previous balance on the log and less the
amount of the expired drug.
d. Two staff members including one pharmacist will initial the entry verifying the accuracy
of the entry and final balance.








Example – Entry for Expired Drugs to Reverse Distributer on Schedule II Narcotic Tracking Log



2. The drug is then placed in a bin or shelf area clearly labeled “Expired Drug”
3. An entry is then made on the “Expired Medication Log” (see appendix F) with the following
elements





Effective Date:

November 2009
 Pharmacy Policy Manual
Chapter: Controlled Substances
□ Operations Procedure Manual
Chapter:

Policy # 7.14

□ Original
Revision August
2016

Page 13
of 14

Title: Schedule II Controlled Substance
Procedures for Community Pharmacies

a. Date the product was moved to the “Expired Drug” inventory.
b. Medication name and strength
c. NDC Number
d. Manufacturers Lot#
e. Product Expiration Date
f. Quantity of Expired Product
g. Two staff members including one pharmacist will initial the entry verifying the accuracy
of the entry.
4. When the reverse distributer collects the expired medication they will complete the
following:
a. Prepare a DEA Form 222 for all medications collected
b. Package the product for shipment
c. Remove the package and ship to their facility
5. For each product provided to the reverse distributer the following is completed.
a. The transaction is handled as a transfer as outlined in section E above.
b. Upon completion of the documentation of the DEA Form 222 and agreement to the
Expired Medication Log , a pharmacist and a technician will document verification on
the Expired Medication log including the date of the transfer to the reverse distributer

V. References and Related Policies and Procedures
A. Pharmacy Policy 7.4 – Controlled Substance Discrepancy Reporting
B. Pharmacy Policy 1.23 – Pharmacy Records Retention
C. DEA Pharmacist Manual



Approved By: ____________________________
Director of Pharmacy Services

Date: ________________