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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