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standard operating procedure college station fire department

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SUBJECT: Medication Exchange and Replacement SOP: 400.3.10<br />

CATEGORY: EMS Procedures PAGE: 4 of 4<br />

College Station Fire Department<br />

Emergency Medical Service<br />

Controlled Drug Usage Form<br />

Call Number: ________________________<br />

Date: _____________________________<br />

Time: ______________________<br />

Name of Patient:<br />

_______________________________________________________________________<br />

Name of Drug: Versed Morphine Nubain (Circle One)<br />

How Ordered: Protocol Physician's Order (Circle One)<br />

Amount Administered: __________________________<br />

Amount Destroyed: ________________________<br />

___________________________________<br />

Witness:<br />

Paramedic Signature:<br />

____________________________________________________________________<br />

Physician Signature:<br />

____________________________________________________________________<br />

(Only if given by direct orders of this Physician)<br />

• • • • • • •<br />

White: Call Report Yellow: Medical Director Pink: Hospital<br />

rev:9/94, 8/95, 4/98, 3/99, 3/02,re#’d 11-02

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