Příloha č. 3
Vzor listu evidenční knihy ostatních zdravotnických zařízení, zařízení sociální péče a při poskytování veterinární péče
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| Název OL I. *, PL II. * (druh, síla a velikost): |
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+--------+-----------------------------+------------+--------+--------+----------+
| | | Použili: | | | Stav |
| | Při příjmu | lékař nebo | Příjem | Výdej | kusů, |
| Datum | | sestra | | | ampulek, |
| příjmu +-------------+---------------+------------+--------+--------+ tablet |
| nebo | série bloku | dodavatel | | | | apod. |
| výdeje | a č.žádanky | | | | | |
| +-----------------------------+------------+--------+--------+----------+
| | Při výdeji | | | | |
+--------+-----------------------------+------------+--------+--------+----------+
| | č. protokolu | nemocný | | | | |
+--------+--------------+--------------+------------+--------+--------+----------+
| 1 | 2 | 3 | 4 | 5 | 6 | 7 |
+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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+--------+--------------+--------------+------------+--------+--------+----------+
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* OL I - omamné látky uvedené v příloze č. 1 zákona č. 167/1998 Sb.
PL II - psychotropní látky uvedené v příloze č. 5 zákona č. 167/1998 Sb.
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