Controlled Drugs Administrative Sheet Republic of the Philippines

Province of Quezon
MAUBAN DISTRICT HOSPITAL
Mauban, Quezon

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 of Patient Patient Room / Name of Prescribing S2 license Physician's Name of Administering PRC License Nurse's Dose Balance Remarks
Adm Adm Hospital ID Bed No. Physician No Signature Nurse No Signature (wastage,
No. etc.)
I hereby certify that above information is true and correct: _________________________________________________________________________________________
Printed Name and Signature of Head Nurse
 Republic of the Philippines
Province of Quezon
MAUBAN DISTRICT HOSPITAL
Mauban, Quezon
HOSPITAL