Form Lic 622 - Centrally Stored Medication And Destruction Record Form

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD
I. CENTRALLY STORED MEDICATION
FACILITY NAME
INSTRUCTIONS: Centrally stored medications shall be kept in a safe and locked place that is not accessible to any person(s)
FACILITY NUMBER
except authorized individuals. Medication records on each client/resident shall be maintained for at least one year.
NAME
(LAST
FIRST
MIDDLE)
ADMISSION DATE
ATTENDING PHYSICIAN
ADMINISTRATOR
STRENGTH/
INSTRUCTIONS
EXPIRATION
DATE
DATE
PRESCRIBING
PRESCRIPTION
NO. OF
NAME OF
MEDICATION NAME
QUANTITY
CONTROL/CUSTODY
DATE
FILLED
STARTED
PHYSICIAN
NUMBER
REFILLS
PHARMACY
LIC 622 (3/99) (CONFIDENTIAL)

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