Form Lic 622b - Psychotropic Medication Administration Record (Mar) Page 2

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES

COMMUNITY CARE LICENSING

If psychotropic medication is prescribed, medication effectiveness and side-effects should be closely monitored according to the monitoring guidelines

provided in the California Guidelines for Psychotropic Medication Use (Appendix B) in conjunction with the Prescribing Physician.

MEDICATIONS NOT ADMINISTERED

Initials

Staff Signature

Date

Hour

Medication Name

Reason

Result

Name:

MO / YR:

All Staff/Caregivers please sign and initial below in order to identify initials.