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Appendix E
Saint Joseph Health System Automated Dispensing Cabinet User Authorization
[ ] Flaget Memorial Hospital
[ ] Saint Joseph Hospital
[ ] Saint Joseph East
[
] Continuing Care Hospital
[ ] Saint Joseph Berea
[ ] Saint Joseph Jessamine
[ ] Saint Joseph Mount Sterling
EMPLOYEE NAME
,
_
Last
First
Middle Initial (
Required)
UNIT
SHIFT
Check your appropriate position:
Registered Nurse
Registered Nurse Applicant
LPN
Physician
Patient Care Tech (OR tech, Rad Tech, etc)
House Administrator
Agency Nurse – Per Diem
Other- Specify:
Agency Nurse – Specify Contract Expiration Date:
Instructor – Specify Expiration Date:
Password Verification Statement
for the Automated Dispensing Cabinets
I understand that my password, in combination with my User ID code, will be my electronic signature for
all transactions to the Automated Dispensing Cabinets (ADC). All of my transactions on the ADC will be
permanently recorded with my User ID and a time stamp and date. These records will be maintained and
archived as per the policies of the hospital and will be available for inspection by the Drug Enforcement
Agency (DEA), the State Board of Nursing, and the State Board of Pharmacy, as is presently done with my
hand-written signature for controlled substance records.
I also understand that to maintain the integrity of my electronic signature, I must not give my password
to any other individual. Sharing of passwords will result in disciplinary action,
up to and including
termination.
(Signature of Automated Dispensing Cabinet user)
(Date)
(Please print full name)
Access authorized by:
Date:
(Nursing Manager/Clinical Educator)
BELOW INFORMATION TO BE COMPLETED BY PHARMACY:
USER ID:
USER INACTIVE DATE:
Entered by:
Date entered:
Revised 3/02, 9/05, 6/07, 6/08, 12/08 n:\PHARMACY\ControlledSubstances\AcuDosePasswordFormSJMS.doc
