Individual Narcotic Count Sheet
|Client name: | |Medication name: | |
|Date of physician’s order: | |Dosage: | |
|Physician’s name: | |Method of administration: | |
| | |Rx number: | |
| | | | |
|[pic] | |
|Office of Developmental Disabilities | |
|Stabilization and Crisis Unit |Individual Narcotic Count Sheet |
DateTimeAmount
on-handAmount receivedAmount givenAmount remainingSignatureWitness signature
Document any discrepancies on the next available line and complete a GER Medication Error Report.
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