Purpose Statement

This article explains how to complete a Custody Exchange for a controlled substance Med Kit from the Dashboard or Med Kits. A Custody Exchange documents the transfer of possession from one provider to another and creates a record of who relinquished and accepted custody.

The workflow can include seal verification, a physical medication count when required, pouch-level inventory verification, and signatures from both the transferring and receiving providers. Users who will continue possessing the Med Kit can instead document that they are retaining custody.

Background Information

Custody Exchange is available for Med Kits configured for controlled substances. Non-controlled substance Med Kits do not display the Custody Exchange option.

A Custody Exchange can be initiated from the Dashboard or directly from the applicable controlled substance Med Kit. When the Scheduling module is used, the Dashboard may automatically display a Med Kit associated with the user's current assignment. Users can also select an applicable Med Kit using the Dashboard's Items selection.

For Med Kits using seals, users begin by entering the physical seal number. If the seal matches the value recorded in the system, the providers can proceed with the custody transfer without breaking the seal or can choose Break and Count. If the seal does not match, Break and Count is required so the medication inventory can be physically verified before custody is transferred.

When a count is required, medications are verified at the pouch level. If the same Medication Form is stocked in multiple pouches, the inventory in each pouch is displayed and verified separately.

Unlike a standard medication count, an active Custody Exchange does not provide Complete and Sign Later. The transferring and receiving providers are expected to complete the signature process while both providers are available.

Required Permissions

Users must have the applicable permissions and access for the functions they need to perform:

• Access to the Medications module.
• Access to the applicable controlled substance Med Kit.
• Ability to initiate and complete a Custody Exchange.
• Dashboard access when initiating the exchange from the Dashboard.
• Applicable signature access based on agency configuration.

A supervisor performing an override must have the applicable permission to perform a Custody Exchange Override.

Video

Medications Par Management

Par management allows medication inventory within a Med Kit to be organized and monitored at the pouch level. When a Custody Exchange requires Break and Count, each configured pouch and its medication inventory are displayed separately for physical verification.

If the same Medication Form is stocked in multiple pouches, users will see and verify the inventory associated with each pouch. This pouch-level verification helps ensure the receiving provider is accepting custody of inventory that accurately reflects what is physically present and supports more precise pouch-level medication event reporting.

Medication cards use color-coding to communicate inventory status when Par and Min values are configured:

• Red – Restock Needed: Available quantity is at or below the configured Min.
• Yellow – Monitor: Available quantity is above Min but at or below Par.
• Yellow – Monitor when Min is not configured: Available quantity is at or below Par.
• Light Gray – Well Stocked: Available quantity is above Par.
• Light Gray – No applicable threshold: A medication may also appear light gray when no Par is configured and inventory remains above Min, or when neither Par nor Min is configured.

Par and Min values are optional. During a Custody Exchange count, use these indicators as inventory-status references while physically verifying the medications being transferred into the receiving provider's custody.

Step-by-Step Guide

1. Start a Custody Exchange from the Dashboard

Open the Medications Dashboard.

Review the applicable Med Kit displayed on the Dashboard. When the Scheduling module is used, the Dashboard may automatically display the Med Kit associated with the user's current assignment.

Use the Items selection to locate another applicable Med Kit when needed.

Select Start Exchange for the applicable controlled substance Med Kit.

2. Start a Custody Exchange from Med Kits

From the Medications module:

• Select Med Kits.
• Select the applicable controlled substance Med Kit.
• Select Custody Exchange.

3. Choose Custody Exchange or Retain Custody

When starting the workflow, choose the action that reflects what is physically occurring:

• Custody Exchange — Transfer possession of the controlled substance Med Kit from one provider to another.
• Retain Custody — Document that the current provider will continue possessing the Med Kit.
• Cancel — Exit without starting the custody workflow.

Select Custody Exchange when another provider is taking possession.

Custody Exchange

Retain Custody

4. Enter the Current Seal Number

For a controlled substance Med Kit configured to use seals:

• Enter the seal number physically present on the Med Kit.
• Select the Plus (+) control.
• Select Save.

The system compares the entered seal number with the seal currently recorded for the Med Kit.

5. Continue When the Seal Matches

When the physical seal matches the seal recorded in the system, choose the appropriate option:

• Proceed to Sign and transfer possession without breaking the seal.
• Select Break and Count to break the seal and physically count the medication inventory before transferring custody.

Follow your agency's policies and procedures when determining whether a full count is required.

6. Break and Count When the Seal Does Not Match

If the physical seal does not match the seal recorded in the system, the workflow requires Break and Count.

Break the seal and proceed with a physical inventory count before transferring custody.

7. Review the Pouches

After selecting Break and Count, review each pouch configured within the controlled substance Med Kit.

Expand the applicable pouches to view their medication inventory.

When the same Medication Form is stored in multiple pouches, verify the inventory in each pouch separately.

8. Review Medication Details

Select each applicable medication card to review its inventory.

Depending on agency configuration and the available inventory, details can include:

• Medication Form
• Quantity
• Expiration date
• Lot number
• Serial number

If multiple Medication Forms exist for a medication, select the medication card to view the individual forms.

9. Verify the Medication Inventory

Physically compare the medications in each pouch with the inventory displayed in the system.

Use the available verification controls:

• Select the Thumbs Up indicator when the physical medication matches the expected inventory.
• Select the X indicator when a discrepancy exists.

Continue until all required medication inventory has been verified.

10. Review Par and Min Status

While counting, review the medication card status as an additional inventory reference.

A yellow medication card indicates inventory is within the applicable Par monitoring range.

A red Restock Needed card indicates inventory is at or below the configured Min.

Par and Min values do not replace the physical count. Verify the actual medications and quantities before accepting custody.

11. Address Medication Discrepancies

If a medication is marked with an X, the discrepancy can generate an occurrence and applicable notifications.

Follow agency procedures for investigating and resolving controlled substance discrepancies.

Do not transfer custody based solely on the system quantity when the physical inventory does not match.

12. Avoid Saving the Custody Exchange as a Draft

After completing the count, Save as Draft may be available.

For normal Custody Exchange workflows, do not use Save as Draft unless the workflow must be interrupted.

13. Save as Draft Only When the Workflow Must Be Interrupted

If an operational need requires the workflow to be interrupted, such as responding to a call:

• Select Save as Draft.
• Seal the Med Kit when appropriate, or select Skip Seal.
• If Skip Seal is selected, enter the required reason.
• Save the draft.

14. Select Sign and Finish

For an uninterrupted Custody Exchange, select Sign and Finish after all required medication inventory has been verified.

Unlike a standard count, Complete and Sign Later is not available during the active Custody Exchange.

Both providers should remain available to complete the custody transfer.

15. Enter the New Seal Number

When the Med Kit requires seals:

• Apply the new physical seal.
• Enter the new seal number.
• If multiple seals are required, enter each applicable seal number.
• Select the Plus (+) control.
• Select Sign.

The workflow proceeds to the Custody Exchange signature process.

16. Complete the Transferring Provider Signature

The provider initiating the Custody Exchange is identified as the Transferring Provider.

Complete the agency-configured authentication and signature requirements.

Depending on agency configuration, this can include:

• PIN
• Password
• A signature filled from the user's profile
• A manually entered signature

17. Complete the Receiving Provider Signature

Select the Receiving Provider who will take possession of the controlled substance Med Kit.

The receiving provider completes the applicable authentication and signature requirements.

After both providers have completed their requirements, select Save to finalize the Custody Exchange.

The receiving provider is then recorded as having custody of the Med Kit.

18. Retain Custody When Possession Is Not Changing

When the current provider will continue possessing the controlled substance Med Kit, start the custody workflow and select Retain Custody instead of Custody Exchange.

Select the applicable retention reason.

Available reasons include:

• Operational
• Shift / Staffing
• Administrative
• Emergency / Contingency
• Other

Enter applicable comments. When Other is selected, a comment is required.

Select Retain Custody and complete the required authentication and signature process.

The current provider remains recorded as having custody.

Best Practices

• Use Custody Exchange only for controlled substance Med Kits when possession is physically transferring between providers.
• Ensure the transferring and receiving providers are both available before beginning the exchange.
• Plan to complete the workflow using Sign and Finish in the same session.
• Avoid Save as Draft during a Custody Exchange. Resuming the draft converts the workflow to a standard count and does not complete the custody transfer.
• Agencies using Exclusive Possession should be especially cautious about interrupting a Custody Exchange because a supervisor may be required to override custody afterward.
• If Exclusive Possession is not enabled and another exchange is started after a draft, verify the Transferring Provider and Receiving Provider carefully before signing.
• Verify physical seal numbers against the system before deciding whether to sign over possession or Break and Count.
• Physically verify every required medication when a Break and Count is performed.
• Review each pouch independently when Medication Forms are stored in multiple pouches.
• Treat Par and Min colors as inventory-status indicators, not substitutes for physical verification.
• Follow agency procedures immediately when a seal or controlled substance inventory discrepancy is identified.
• Enter the new seal number carefully before completing signatures.
• Confirm that the correct receiving provider is selected before finalizing the exchange.
• Use Retain Custody when the same provider will continue possessing the Med Kit rather than creating an unnecessary transfer between providers.

Troubleshooting & FAQs

Why don't I see Custody Exchange on a Med Kit?

Custody Exchange is available for applicable controlled substance Med Kits. A Med Kit configured as non-controlled substance does not display the Custody Exchange option.

Can I start a Custody Exchange from the Dashboard?

Yes. Applicable exchanges can be started from the Dashboard using Start Exchange or directly from the controlled substance Med Kit.

What happens if the seal matches?

When the physical seal matches the seal recorded in the system, you can proceed with the custody signature process without breaking the seal or select Break and Count when a physical count is required.

What happens if the seal does not match?

The workflow requires Break and Count so the physical medication inventory can be verified. Follow agency procedures for reporting the seal discrepancy.

Do I need to count the medications during every Custody Exchange?

Not necessarily. A seal-secured Med Kit with a matching seal can allow the providers to proceed without breaking the seal. When Break and Count is required or selected, the physical inventory must be verified.

Why do I see the same medication in multiple pouches during the count?

The Medication Form is configured in multiple pouches. Each pouch maintains separate inventory and must be verified independently.

Why isn't Complete and Sign Later available?

An active Custody Exchange requires the transferring and receiving providers to complete the custody signature process. It cannot be finalized as a pending signature using Complete and Sign Later.

Can I save a Custody Exchange as a draft?

The count portion can provide Save as Draft, but doing so is not recommended for normal Custody Exchanges. When resumed, the workflow becomes a standard medication count rather than resuming the Custody Exchange.

Why does Complete and Sign Later appear after I resume my draft?

The saved workflow has resumed as a standard count, not a Custody Exchange. Standard count completion options therefore become available.

Does completing the resumed count transfer custody?

No. Completing the resumed standard count does not complete the original transfer of custody.

Why does a supervisor need to perform a Custody Exchange Override after my draft?

If Exclusive Possession is enabled and the Custody Exchange was interrupted, the existing custody assignment can prevent another provider from taking custody normally. An authorized supervisor must use the Custody Exchange Override process to resolve the custody assignment.

What happens if Exclusive Possession is not enabled and I start another Custody Exchange after saving the first one as a draft?

The Transferring Provider can default to your name even when you are intended to be the Receiving Provider. Verify the provider roles carefully before completing the exchange.

What happens if a medication is marked with an X during the count?

The discrepancy can generate an occurrence and applicable notifications. Follow agency policy for investigating and resolving controlled substance discrepancies.

Who is the Transferring Provider?

During the normal Custody Exchange workflow, the provider initiating the exchange is identified as the Transferring Provider.

Who is the Receiving Provider?

The Receiving Provider is the individual selected to take possession of the controlled substance Med Kit. That provider completes their own applicable authentication and signature requirements.

When should I use Retain Custody?

Use Retain Custody when the current provider will continue possessing the controlled substance Med Kit, such as remaining on duty for additional staffing or another agency-defined reason.

Is a comment required when retaining custody?

Comments can be added to document the circumstances. When Other is selected as the retention reason, a comment is required.