Controlled Substance Log Entry (Dispense/Administer)

Transaction Type

Transaction Type: [Dispense / Administer / Administer + Waste] (Required. Selection controls conditional sections below.)

Entry Metadata

Entry ID: [System-generated unique identifier] (Auto-generated; immutable once created.)

Entry Status: [Draft / Final / Amended]

Date/Time of Event: [YYYY-MM-DD HH:MM with timezone] (Actual time of dispense or administration.)

Date/Time of Documentation: [System timestamp]

Registered Location/Site: [Facility name] — [Unit/Clinic/OR sub-location]

Source Inventory Location: [Vault/Cabinet/ADC name] — [Bin/Drawer if applicable]

Controlled Substance Schedule: [II / III / IV / V]

Encounter ID or Case ID: [Identifier] (Optional; include when relevant for reconciliation.)

(If Entry Status = Amended, include the following)

Amendment Reason: [Brief description of correction]

Amended By: [Name, credentials, authenticated user ID]

Amendment Date/Time: [YYYY-MM-DD HH:MM with timezone]

Original Entry ID: [Linked Entry ID] (Original record remains visible and auditable.)

Patient Identification

Patient Full Legal Name: [Last, First, Middle]

Date of Birth: [YYYY-MM-DD]

Patient Identifier: [MRN or equivalent]

Patient Address: [Street, City, State/Province, Postal Code, Country] (Snapshot at time of transaction. If unavailable, entry must remain Draft with explanation below.)

Address Unavailable Reason/Plan: [Explanation and how it will be obtained] (Only include if address is unavailable.)

Medication Identification

Medication Name: [Generic drug name] (Generic preferred.)

Dosage Form: [Tablet / Capsule / Vial / Syringe / Patch / Solution / Other]

Strength/Concentration: [Numeric value with units, e.g., 50 mcg/mL]

Package Size: [e.g., 2 mL vial, 10 tablets]

Units of Measure: [mL / mg / mcg / tablet / patch / other] (Use consistently in Quantity Movement section.)

NDC: [National Drug Code] (Optional; include when tracked at point of care.)

Lot/Batch Number: [Lot/Batch] (Optional; include when tracked at point of care.)

Expiration Date: [YYYY-MM] (Optional; include when tracked at point of care.)

Lot/NDC Unavailable Reason: [Not labeled / Removed without capture / Other] (Only include if lot tracking is required but unavailable.)

Authorization / Order Linkage

Authorizing Clinician: [Name, credentials] (May auto-populate from linked order.)

Authorization Type: [Prescription / Medication Order / Protocol / Standing Order / Verbal Order]

Order/Prescription ID: [Rx number / eRx ID / CPOE order ID]

Indication/Reason for Use: [Brief indication]

(If Authorization Type = Verbal Order, include the following)

Verbal Order Verification: [Verifier name, credentials, date/time of verification]

Quantity Movement

Quantity Removed From Stock: [Numeric value] [Units]

(If Transaction Type = Dispense)

Quantity Dispensed: [Numeric value] [Units] (Must be ≤ Quantity Removed.)

(If Transaction Type = Administer or Administer + Waste)

Quantity Administered: [Numeric value] [Units] (Must be ≤ Quantity Removed.)

Route: [IV / IM / SQ / PO / SL / PR / Transdermal / IN / Other]

Dispensed/Administered By: [Printed name, credentials, or authenticated user ID]

Waste / Remainder

(Include this section only when Transaction Type = Administer + Waste OR when Quantity Administered < Quantity Removed.)

Quantity Wasted: [Numeric value] [Units]

Waste Method: [Per facility policy]

Waste Date/Time: [YYYY-MM-DD HH:MM with timezone]

Reason for Waste: [Partial dose / Overfill / Contamination / Patient refused / Discontinued / Other]

Witness Name and Credentials: [Name, credentials] (Required if facility policy mandates witnessed waste.)

Witness Attestation: [Checkbox] "I directly witnessed the waste as documented."

No Witness Available — Exception Documentation: [Explanation and supervisor review pathway] (Only include if witness required but unavailable.)

Attestation

Primary Attestor: [Name, credentials, authenticated user ID]

Primary Attestor Date/Time: [System timestamp at authentication]

Witness Attestation: [Name, credentials, authenticated user ID, system timestamp] (Include if witness required by policy.)

Finalization Statement: [Checkbox] "I attest this entry is complete and accurate to the best of my knowledge." (Once finalized, the record is immutable. Corrections require Amendment/Addendum linked to the original entry.)