Controlled Drugs Administration Sheet

Republic of the Philippines

Provincial Health Office
ORIENTAL MINDORO CENTRAL DISTRICT HOSPITAL
Papandayan, Pinamalayan, Oriental Mindoro

RECORD OF DANGEROUS DRUG PREPARATION AND DRUG PREPARATIONS CONTAINING CONTROLLED CHEMICAL
DISPENSED TO IN- PATIENTS (THROUGH FLOOR STOCK)

With Reference to Requisition No: ___________________________ Date: ___________________

Name of Controlled Drug Preparation: ___________________________
Quantity: ___________________________

Date of Time of Full Name Patient Room / Name of S2 Physician’s Name of PRC Nurse’s Dose Balance Remarks
Adm Adm of Patient Hospital Bed No. Prescribing License Signature Administering License Signature (wastage,
ID No. Physician No Nurse No. etc.)

I hereby certify that above information is true and correct: ___________________________________________________

Printed Name and Signature of Head Nurse