Patient Name
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First Name
Last Name
Date Drugs Administered
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Month
-
Day
Year
Date
KETAMINE
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of
Vial Number
Administered (mg)
Wasted (mg)
FENTANYL
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Vial Number
Administered (mcg)
Wasted (mcg)
MIDAZOLAM
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of
Vial Number
Administered (mg)
Wasted (mg)
REMIFENTANIL
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of
Vial Number
Administered (mg)
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