Share

Requisition Sheet

PDEA requisition sheet for dangerous drug preparation

Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Requisition Sheet
HOSPITAL LETTERHEAD

REQUISITION FOR DANGEROUS DRUG PREPARATION
OR DRUG PREPARATION CONTAINING CONTROLLED CHEMICAL
FOR IN-PATIENT USE
Requisition No: # /Ward or Unit/Calendar Year

Date: _____________

To: The Chief Pharmacist
Request for _(Pls encircle, as appropriate: initial / replenishment )_ emergency/floor stock of the
controlled drug named hereunder:
Name of controlled drug,
dosage strength and form

Quantity

Ward/Unit where needed

(Note: Only 1 drug strength and form per requisition)

The undersigned undertakes to submit the corresponding Administration Sheet to fully account the disposition
of the requested controlled drug and to facilitate replenishment of stock. Further, take full responsibility and
accountability on subject controlled drug.

______________________________________________
Printed Name and Signature of Nurse-In-Charge

Conforme:

_______________________________________________
Printed Name and Signature of Physician on duty

****************************************************************************************************************************
This portion to be filled-out by the Pharmacist:
[

] APPROVED.

________________________________________________

[

] DISAPPROVED.

State reason:__________________

Printed Name, Signature of Dispensing Pharmacist / Date

****************************************************************************************************************************

________________________________________________
Printed Name, Signature of Receiving Nurse /Date)

Controlled Drugs Administration Sheet

HOSPITAL LETTERHEAD

RECORD OF DANGEROUS DRUG PREPARATION AND DRUG PREPARATIONS CONTAINING CONTROLLED CHEMICAL
DISPENSED TO IN-PATIENTS (THROUGH FLOOR STOCK)
With Reference to Requisition No:
____________________________
Name of Controlled Drug Preparation: ____________________________
Quantity:
____________________________
Date of
Adm

Time of
Adm

Full Name of
Patient

Patient
Hospital
ID No.

Room /
Bed No.

Name of
Prescribing
Physician

Date: _____________________

S2 License
No

Physician’s
Signature

Name of
Administering
Nurse

PRC
License
No

I hereby certify that above information is true and correct: ___________________________________________________________
Printed Name and Signature of Head Nurse

Nurse’s
Signature

Dose

Balance

Remarks
(wastage,
etc.)
 
Page of
Share