General Hospital • Operating Theatre

Narcotic Drug Endorsement Form

FORMULA: (Opening Balance) + (Received) - (Used) - (Wasted) - (Returned) = Closing Balance
No. Drug Name & Strength Opening
Balance		 Received
(From Pharm)		 Total
(Open + Rec)		 Used /
Admin		 Wasted /
Broken		 Returned
(To Pharm)		 Closing
Balance		 Remarks / Notes
1
2
3
4
5
6
7
8
9
10
11
12
13
14

Discrepancies & Wastage Notes

Note: Any wasted/broken ampoule must be witnessed. Any discrepancy in count must be escalated immediately to the Charge Nurse and Pharmacy.

Shift Handoff Verification

1. Handing Over Nurse

2. Taking Over Nurse

3. Charge Nurse Verification