Controlled Substance Administration Documentation
Purpose/ Applicability: To describe the appropriate process for documenting administration of controlled substances.
Scope: This applies to all controlled substances administered in the VTH, VMSC, WMC, and Midwest Equine and by all associated services. This also applies to controlled substances obtained through the Medication Dispensary for research use.
Definition(s):
- Anesthesia Flow Sheet: The anesthesia record which includes documentation of the drugs administered and two signatures.
- Controlled Substance: A drug or other substance, or immediate precursor, included in schedule I, II, III, IV, or V of part B of Title 21 USC Controlled Substances Act. This term does not include distilled spirits, wine, malt beverages, or tobacco.
- EQ Medication Administration Record (pink sheet): The form used to document controlled substance administration for equine patients and then turned into Medical Records
- Euthanasia Form (blue sheet): Euthanasia/Care of Remains Authorization and Release form.
- Medication Administration Record (purple sheet): The form used to document controlled substance administration and then turned into Medical Records
- Sedation Administration and Monitoring Record: The form for documenting sedation monitoring which includes documentation of the drugs administered with two signatures.
- Vial Log (yellow sheet): A running inventory log associated with a vial of controlled substance. These are provided by the Medication Dispensary when appropriate.
- Witness: A person that can attest to the fact that the controlled substance was given to the patient. This person is in addition to the person administering the medication. There are no specific qualifications for this person.
Equipment:
- Applicable form for documenting controlled substance administration. The forms approved for this purpose are listed below.
o Anesthesia Flow Sheet
o EQ Medication Administration Record (pink sheet)
o Euthanasia Form (blue sheet)
o Medication Administration Record (purple sheet)
o Sedation Administration and Monitoring Record
o Vial Log (yellow sheet)
Procedure:
All controlled substances obtained from the Medication Dispensary will require a signature by the person picking up the medication at the time of pickup.
To determine the appropriate method of controlled substance administration documentation, use the flow chart below
