Controlled Substance Administration Report

Controlled Substance Administration Report

Complete one form per patient.
Date*

MonthDayYear
Unit*
Incident number*
Patient name*

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

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