Purpose Statement

This article explains how to complete a Custody Exchange for controlled substance kits from either the Dashboard or Med Kits. This feature ensures DEA compliance by maintaining a complete chain of custody audit trail, preventing unauthorized access to medications, and documenting secure possession transfers with dual-signature authentication. By restricting medication events to only the user who currently possesses the kit, this system prevents accidental medication entries and enhances accountability for all controlled substance handling.

Background Information

Custody Exchange is used to document accountability for controlled substance kits. Depending on agency policy and kit security configuration, users may either:

• Transfer possession to another individual

• Retain custody and document the reason for continued possession

For agencies using seals, the workflow may require seal verification before completing the exchange. If seals do not match, an occurrence may need to be reported and a Break and Count completed. For agencies using locks, a full count is required before possession can be transferred.

Required Permissions

Users must have appropriate permissions within the Medications module to complete a custody exchange.

Typical permissions may include:

• Medications Module Access

• Controlled Substance Kit access

• Custody Exchange permissions

• Dashboard access

• Med Kit access

• Signature permissions

• Occurrence reporting permissions, if applicable

Permission availability may vary based on agency configuration.

Video

Step-by-Step Guide

1. Navigate to Dashboard or Med Kits

1. Navigate to the Medications module.

2. Select either Dashboard or Med Kits.

A Custody Exchange for controlled substance kits can be completed from either location.

2. Start the Exchange from the Dashboard

1. From the Dashboard, filter the COUNTS list using the Items dropdown.

2. Select the kits currently in your possession.

3. If an exchange is due, select Start Exchange.

3. Start the Exchange from Med Kits

1. From Med Kits, select the kit currently in your possession.

2. To begin the exchange, select either:

   • Custody Exchange button, or

   • Custody Exchange icon

4. Confirm Kit Possession

1. If you do not currently possess the selected kit, you will not be able to perform a Custody Exchange.

5. Choose a Custody Exchange Option

Once Custody Exchange is selected, you will have three options:

• Cancel – Cancels the custody exchange

• Retain Custody – Use when you will continue to possess the controlled substance kit but need to document retention for compliance tracking

• Custody Exchange – Use when transferring possession from one person to another

6. Select a Retention Reason

If Retain Custody is selected:

1. Choose a reason for retention from the dropdown menu:

• Operational – Operational needs requiring continued custody

• Shift / Staffing – Holdover for overtime, shift trade, or staffing coverage

• Administrative – Administrative decisions requiring retention

• Emergency / Contingency – Emergency situations requiring continued possession

• Other – Any other reason for custody retention

If Other is selected, a comment is required.

7. Add Comments and Complete Retain Custody

1. Enter any relevant details in the Comments field.

2. Comments are optional but recommended unless Other is selected, in which case comments are required.

3. Select Retain Custody.

4. Follow your agency’s signature process to complete the workflow.

8. Enter Seal Numbers for a Custody Exchange

If Custody Exchange is selected and your agency uses seals for controlled substance kits:

1. Enter the seal number(s) in the field.

2. Select the Plus (+) icon to add the seal number(s).

3. Select Save to continue the exchange.

If seal numbers do not match:

1. Select Report to report an occurrence.

2. You must then perform a Break and Count.

9. Choose Sign Over Possession or Break and Count

1. If the seal number matches, the system will provide the option to:

   • Sign over possession, or

   • Break and Count

10. Complete a Count for Lock-Secured Kits

1. If your agency uses locks for controlled substance kits, you must perform a count before signing over possession.

Best Practices

• Verify that you are the current possessor of the kit before starting the workflow.

• Use Retain Custody only when continued possession is required and permitted by policy.

• Enter clear comments whenever retention or seal discrepancies need additional explanation.

• Double-check seal numbers before saving to avoid unnecessary occurrence reporting.

• Complete required counts carefully for kits secured with locks or when seals do not match.

Troubleshooting & FAQs

Why can’t I complete a Custody Exchange for a kit?
You must currently possess the selected kit to perform a custody exchange.

When should I use Retain Custody instead of Custody Exchange?
Use Retain Custody when you are keeping possession of the controlled substance kit but need to document that retention for compliance purposes.

What happens if the seal numbers do not match?
You can report an occurrence by selecting Report, and you must complete a Break and Count before finishing the workflow.

Do I always need to count the kit before signing it over?
Not always. For seal-secured kits with matching seals, the system may allow you to sign over possession without a full count. For lock-secured kits, a count is required.

Is a comment required when retaining custody?
A comment is only required when Other is selected as the retention reason, but comments are recommended for all retention entries.