Draw & Waste SOP
Standard operating procedure for recording controlled-substance draws, wastes, reversals, and dual-witness C-II requirements. Print and post this in each treatment room.
Purpose & scope
This SOP governs the real-time recording of controlled-substance draws, wastes, blind counts, reversals, and adjustments in VetRx Ledger for all Schedule II–V substances maintained at a licensed veterinary facility. It applies to every veterinarian, licensed veterinary technician, and practice manager who handles controlled substances at the facility.
Roles & responsibilities
| Role | Responsibility |
|---|---|
| DEA Registrant (DVM/Owner) | Ensures compliance; countersigns monthly reconciliation |
| Administering DVM | Orders and supervises administration; enters DVM ID on DRAW events |
| Lead Technician | Draws medication; enters event; serves as primary witness for C-III–V wastes |
| Second Witness | Required for all C-II wastes; must be a licensed DVM or LVT distinct from the drawer |
Event types
| Type | When to use | Witness required? |
|---|---|---|
| DRAW | Any time a dose is drawn from a vial for administration | No |
| WASTE | Any amount discarded (e.g. remaining dose after use) | Yes for C-II; recommended for C-III–V |
| REVERSAL | Error correction — quantity returned to vial (rare; document reason) | No, but auditable |
| BLIND_COUNT | Periodic physical count without adjustment; records inventory snapshot | No |
| ADJUSTMENT | Variance correction after reconciliation review (signed off by DEA registrant) | Recommended |
Procedure — DRAW
- Retrieve the vial from the secured safe. Confirm drug name, lot, and expiry match VetRx Ledger.
- Open Ledger → select DRAW.
- Select the vial from the dropdown (scan barcode to auto-select if available).
- Enter quantity drawn in the labelled unit (mL, mg, or mcg — be consistent with the vial record).
- Enter administering DVM ID and your technician ID.
- Tap Submit Event. Confirm the running balance decrements correctly.
- Return any multi-dose vial to the safe immediately.
Procedure — WASTE (C-II)
- Do not discard the waste until a second witness is present and logged in.
- The primary recorder opens Ledger → selects WASTE → selects the vial.
- VetRx Ledger will prompt: "A witness session is required for C-II waste."
- The primary recorder clicks Create witness session. VetRx Ledger generates a short-lived session token (expires in 10 minutes).
- The second witness opens VetRx Ledger on their own device or login, navigates to Ledger → Witness, and enters the session token.
- The witness authenticates (PIN, hardware key, or biometric depending on your configuration) and submits.
- VetRx Ledger issues a one-time
witnessToken. The primary recorder pastes or scans this token into the waste form. - Both parties physically observe the waste (flush, crush, or other approved method).
- Primary recorder enters waste quantity and submits. Both user IDs are recorded in the append-only ledger entry.
witnessToken. There is no override or bypass. Contact hello@grantshelf.com if you encounter an error.Procedure — BLIND_COUNT
Perform a blind count at least monthly (ideally weekly for high-volume clinics). The person counting should not have access to the current electronic balance beforehand.
- Physically count every vial in the safe and note quantities on paper.
- Open Ledger → select BLIND_COUNT for each vial.
- Enter the physical count quantity. VetRx Ledger records this as a snapshot event without adjusting the running balance.
- After submitting all blind counts, navigate to Reconcile to compare physical counts against computed balances.
- Variances > 2% must be investigated and documented before the next business day.
Discrepancy response
| Variance | Action |
|---|---|
| < 1% | Document in reconciliation notes; monitor next cycle |
| 1–5% | Review event log for data-entry errors; submit ADJUSTMENT with DVM sign-off |
| > 5% or unexplained | Notify DEA registrant immediately; consider filing DEA Form 106 |
Record retention
All events are stored in an immutable, hash-chained ledger with hardware-backed e-signatures. VetRx Ledger retains records for a minimum of 2 years (DEA requirement) with options to export CSV or JSON chain-of-custody packages at any time. Do not delete event entries; use REVERSAL or ADJUSTMENT with documented reason instead.
Download Printable SOP Template
Download this SOP as a formatted PDF to print, sign, and file in your physical controlled substance logbook. Fill in your practice name and DEA registration number before posting. Keep a signed copy on file per 21 CFR §1304.04.
⬇ Download Daily Logging SOP PDF