Medical Staff House Staff Orientation Manual - Montefiore Medical ...

CONTROLLED SUBSTANCES IN THE MEDICAL CENTER
It is the policy of the Medical Center to comply with federal, state and local regulatory agencies
pertaining to the ordering, receiving, storing, documentation and distribution of all controlled
drugs (CIIV) and to keep accurate records of each transaction. It is expected that all practitioners
who are authorized to administer or prescribe controlled substances in the medical center
conform to the requirements set forth by federal, state and medical center regulations.
The Department of Pharmacy will perform routine inspections and audits of all controlled
substance inventories to insure adherence to medical center policies and procedures and state and
federal regulations.
AUTHORIZED PRESCRIBERS
According to the New York State Department of Health Bureau of Controlled Substances and
MMC policy, the following practitioners are authorized to prescribe controlled substances in the
medical center: Doctors of Medicine, Doctors of Osteopathy, Dentists, Medical
Interns/Residents, Physician Assistants, Midwives, Nurse Practitioners, Optometrists and
Podiatrists.
• Orders for controlled substances written by registered physician assistants must be
countersigned by the collaborating physician within 24 hours.
• Medical students must have their orders countersigned by the resident or attending physician
before the order can be processed and administered to the patient.
• Interns, residents, and foreign physicians are allowed to write controlled substance
prescriptions provided that: 1.) Prescribing is done in the usual course of the practitioner's
professional practice. 2.) The practitioner acts only in the scope of his employment in the
hospital. 3.) The DEA number with a hospital-assigned three-digit suffix is received. Staff
physicians who are qualified to obtain their own DEA numbers may not use a hospital
number.
WRITTEN INPATIENT STANDING AND ROUTINE ORDERS FOR CONTROLLED
SUBSTANCES:
• Must be patient specific and written by an MMC authorized practitioner
• Must state the name of the drug, dose, route and frequency of administration.
• Orders that give a dose range (e.g., 50-100mg) or more than one route (e.g., PO/IM) are not
allowed.
• Preprinted orders are not allowed.
• All orders must have the prescriber signature and countersignature where applicable
• Orders written to be administered PRN without a specific time or frequency (e.g. Ativan lmg
P.O. PRN) are valid only for 72 hours. An order without a specific time may be administered
once only within the 72-hour period. A new order must be written if additional doses are
required.
• Specific orders for controlled substances to be administered at specific times are valid for
seven days and must be rewritten at least every seven days. The specified time may include a
PRN notation to allow the drug to be administered in accordance with the patient's need (e.g
Phenobarbital 15 mg P.O. t.i.d. and H.S.Valium 5 mg P.O. t.i.d. prn and Restoril 30 mg PO.
H.S. prn).
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