Records and Record Keeping

Figure 4.2. Controlled drugs and log.


When dispensing controlled drugs to a patient in the hospital, it’s important to include the following information in the drug logbook (Fig. 4.2):

1. Patient’s full name and identification number

2. Date and name of drug, including dose in mL and mg

3. Initials of the individual drawing up the drug as well as the doctor overseeing the case

The logbook should be maintained with bound pages containing sequentially printed page numbers. This type of system, unlike that of a three-ring binder, makes it hard to alter any information that would render the record an untrustworthy document.

Computer systems with software that allows minimal editing of entries and uneditable notes of any changes made to preexisting entries can also be used to legally document controlled substances. These systems should not allow any deletions or alterations of records without the traceable fingerprint of such acts.

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Aug 12, 2017 | Posted by in SUGERY, ORTHOPEDICS & ANESTHESIA | Comments Off on Records and Record Keeping
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