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Documentation of Controlled Substance Use in UWHC Clinics (7.6)

Documentation of Controlled Substance Use in UWHC Clinics (7.6) - Policies, Clinical, UWHC Clinical, Department Specific, Pharmacy, Controlled Substances

7.6





Effective Date:

December 2001
Pharmacy Policy Manual
Chapter: Controlled Substances
Operations Procedure Manual
Chapter:

Policy #: 7.6

 Original
 Revision 10/16

Page 1
of 3

Title: Documentation of Controlled Substance
Use in UWHC Clinics

I. PUPRPOSE: The purpose of this policy is to outline procedures for use of controlled
substances in UWHC clinics that ensure proper control, accountability, and documentation is
in place to comply with DEA requirements and minimize chance for drug diversion.

II. POLICY: Nursing shall be responsible and accountable for documenting all administered
doses of controlled substances on the Narcotic Sign Out Sheet and to complete an audit each
day verifying the accuracy of the documentation and verify that on hand amounts match
inventory levels noted on Narcotic Sign Out Sheet at the beginning of each day.

III. FORMS:
A. Narcotic Sign Out Sheet
B. Daily Narcotic Usage - Clinics

IV. PROCEDURE:
A. Controlled substances will be stocked in tamper proof packaging.
1. A tamper proof item cannot be returned to stock once it has been opened.
B. Documentation of all controlled substance (CS) medications.
1. Upon receiving an order for a controlled substance, the nurse shall write the following
information on the Narcotic Sign Out Sheet.
a. Patient name.
b. Nurse's initials.
c. Number of doses used in the appropriate medication column.
d. The patient’s medical record number (MR#).
e. Amount wasted due to defective, broken, contaminated syringes, or partially used
doses shall be documented by completing an entry on the Narcotic Sign Out Sheet
i. This entry shall be signed by two nursing personnel.
f. If opened, the tamper proof controlled substance must be wasted by the nurse and
this waste witnessed by a second nurse and documented on the Narcotic Sign Out
Sheet.
C. Accounting for controlled substance medication at change of shift.
1. A new Narcotic Sign Out Sheet will be started each day.
2. The ending balance from the previous day will be transferred to the next day’s
Narcotic Sign Out Sheet for beginning balance information.
3. Completed Narcotic Sign Out Sheet from the previous day shall be left for the Clinics
Pharmacy Technician to pick up.
4. The charge nurse (or designee) will be responsible for conducting an audit of all
controlled substance medications used during the previous day.
a. The column of each medication will have a running balance of what is on hand in
the clinic area.





Effective Date:

December 2001
Pharmacy Policy Manual
Chapter: Controlled Substances
Operations Procedure Manual
Chapter:

Policy #: 7.6

 Original
 Revision 10/16

Page 2
of 3

Title: Documentation of Controlled Substance
Use in UWHC Clinics

b. The nurse will sign the bottom of the form on the appropriate blank to confirm an
accurate audit verifying amount on hand with the amount recorded for the end of
day balance.
c. If a discrepancy exists at the time of the audit which can not be resolved through
appropriate investigation of the previous day activity, a narcotic discrepancy form
shall be completed by the charge nurse or designee (see Pharmacy Policy 7.4-
Controlled Substance Discrepancy Reporting) and provided to the Clinics
Pharmacy Technician. The names of all potentially involved personnel shall be
recorded on the narcotic discrepancy report form.
d. The charge nurse or designee will also record the discrepancy on the Narcotic
Sign Out Sheet stating “missing dose-discrepancy report filed" followed by his/her
initials.
i. Pharmacy will monitor discrepancy trends and will follow up with appropriate
clinic manager as needed.
D. Restocking of the Controlled Substance Cabinet by Clinics Pharmacy Technician.
1. The Clinics Pharmacy Technician will not replace any narcotics until the previous
days Narcotic Sign Out Sheet has been completed and made available.
2. The Clinics Pharmacy Technician will review the previous days Narcotic Sign Out
Sheet to determine which narcotics and amounts to re-supply.
3. The Clinics Pharmacy Technician will dispense narcotics from the clinic narcotic box.
4. Addition of narcotics to the clinic supply will be documented as follows:
a. "RESTOCK" noted in the patient column of the Narcotic Sign Out Sheet
b. Initials of the Clinics Pharmacy Technician recorded next to “RESTOCK”.
c. Charge nurse or designee will review those drugs being added as "RESTOCK"
and verify the added drugs and amounts and will co-initial the technician
"RESTOCK" entry.
E. Daily audit of Narcotic Control Documentation
1. For each Narcotic Sign Out Sheet the Clinics Pharmacy Technician will verify the
following:
a. A nurse has signed for all administrations
b. The beginning shift balance is recorded
c. A nurse has signed for initial balance.
d. Ending shift balance recorded
e. A nurse has signed for ending balance.
f. A Technician and a nurse have signed for each restock event
g. Two signatures are present (on the right side of Narcotic sheet) for all waste
events.
h. Beginning balance matches ending balance of prior day
2. Any deficiencies in documentation will be corrected by the clinic, or a discrepancy
report will be prepared by the Clinics Pharmacy Technician





Effective Date:

December 2001
Pharmacy Policy Manual
Chapter: Controlled Substances
Operations Procedure Manual
Chapter:

Policy #: 7.6

 Original
 Revision 10/16

Page 3
of 3

Title: Documentation of Controlled Substance
Use in UWHC Clinics

3. The Clinics Pharmacy Technician will summarize the quantity replaced in each clinic
on the Daily Narcotic Usage – Clinics form.
4. The Clinics Pharmacy Technician will provide the Daily Narcotic Usage Form and all
supporting Narcotic Sign Out Sheets to the NarcStation Technician with the clinic
box.
F. Resupply of Clinic Narcotic Box and Verification of Supporting Documentation
1. The NarcStation Technician will verify that all doses used from the clinic box are
accounted for when refilling the clinic box and that the totals from the Daily Narcotic
Usage – Clinics form matches the amount needed to bring the clinic box to standard
a. A discrepancy report will be prepared by the NarcStation for any dose that does
not have complete documentation.
2. The NarcStation Technician will forward a complete packet containing the Daily
Narcotic Usage form and supporting Narcotic Sign Out Sheets to the administrative
support staff in the pharmacy office who will charge the patients with each
medication administered.
3. After billing all medications, the administrative support staff will forward the packet
to the Pharmacy Manager of Business Operations for review and filing.
G. The Narcotic Sign Out Sheets, Daily Narcotic Usage form, and the clinic box narcotic
sign out sheet are kept on file for 5 years.

V. REFERENCES AND RELATED POLICIES, PROCEDURES
A. Pharmacy Policy 7.4 – Controlled Substance Discrepancy Reporting
B. Pharmacy Policy 1.23 – Pharmacy Records Retention

VI. COORDINATION:
A. AUTHORED BY: Dave Musa
B. COMMITTEE APPROVAL BY: None



Approved By: ____________________________
Director of Pharmacy Services

Date: ________________