Controlled Substance Administration Report

Controlled Substance Administration Report

Complete one form per patient.
Date *

Month Day Year
Unit *
Incident number *
Patient name *

First Name Last Name
Which medication(s) are you reporting administered and/or wasted? *

Fentanyl Ketamine Midazolam (Versed) Morphine
Any wastage of a controlled substance must be witnessed by a Registered Nurse, Physician, or Medstar Supervisor.