"Client Injectable Medication Log" - County of Santa Clara, California

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Download "Client Injectable Medication Log" - County of Santa Clara, California

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Client Injectable Medication Log
Drug Name: ______________________
NDC #: _________________
Manufacturer
Dose
Expiration
Date
convert to
Date
Client Name
Unicare #
Opened
Dose (mg)
Date
mL
Comments:
1. NDC # refers to the 10 digit National Drug Code found on each vial.
2. For MDV, the vial needs to be dated when open.
3. Un-used portion expires after 30 days from open date and should be returned to Pharmacy.
4. Use one vial at a time (Do not keep multiple open vials on hand).
Client Inj Med Log
5. Keep log on file for 1 year.
rev. 03/02/07
Client Injectable Medication Log
Drug Name: ______________________
NDC #: _________________
Manufacturer
Dose
Expiration
Date
convert to
Date
Client Name
Unicare #
Opened
Dose (mg)
Date
mL
Comments:
1. NDC # refers to the 10 digit National Drug Code found on each vial.
2. For MDV, the vial needs to be dated when open.
3. Un-used portion expires after 30 days from open date and should be returned to Pharmacy.
4. Use one vial at a time (Do not keep multiple open vials on hand).
Client Inj Med Log
5. Keep log on file for 1 year.
rev. 03/02/07
Order Form For Haloperidol And Fluphenazine Decanoate Injection
Clinic Name: _________________________
Date: _________________________
Requester Name: _____________________
Pharmacy
Clinic
Quantity
Quantity
Staff
Staff
Drug Name & Strength
Requested
Provided
Signature
Signature
Haloperidol Decanoate 50mg/ml
5ml Multi-Dose Vial
Pharmacy Use Only
NDC#
Lot #/s
Manuf. Exp
Date/s
Haloperidol Decanoate 100mg/ml
5ml Multi-Dose Vial
Pharmacy Use Only
NDC#
Lot #/s
Manuf. Exp
Date/s
Fluphenazine Decanoate 25mg/ml
5ml Multi-Dose Vial
Pharmacy Use Only
NDC#
Lot #/s
Manuf. Exp
Date/s
•Maximum Supply to be Stocked is six vials of each of the above depending on your usage.
•Keep log on file for 1 year at clinic.
•Please reorder when you have two vials on hand.
Injectable Med Requisition Form
rev 3/01/07
County of Santa Clara Mental Health Department
Refrigerator Temperature Log
Site:
Month/Year:
Location: Med Room
Temp °F(°C) Date
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
50 (10)
49 (9.4)
48 (8.9)
47 (8.3)
46 (7.8)
45 (7.2)
44 (6.7)
43 (6.1)
42 (5.5)
41 (5)
40 (4.4)
39 (3.9)
38 (3.3)
37 (2.8)
36 (2.2)
35 (1.7)
34 (1.1)
33 (.5)
32 (0)
31 (-.5)
30 (-1.1)
1. Place an "X" in the box of the observed temperature. Record time and initial.
2. If out of range (gray area), adjust the thermostat. In 1 hour, reread and record new temperature. If still out of range, contact Enborg
Lane Pharmacy (885-4100) or Downtown Pharmacy (299-6066) for drug stability information and report to clinic manager. If necessary, the
medications should be moved to a working refrigerator until the temperature is within range.
Medication Destruction Log Sheet
From: ________________________________(Clinic Name)
To: □ Downtown Center Pharmacy
□ Enborg Lane Pharmacy
Date RX Sent To
RX Name & Strength OR
Clinic Staff
RPh
Pharmacy
Patient Name
Name&Initial
Courier Name
Name&Initial
Quantity
Keep log on file at clinic for 1 year.
Med Destruction Log
rev 3/01/07
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