Form Lic 622b - Psychotropic Medication Administration Record (Mar) Page 4
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4STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
PLACEMENT WORKER NAME & NUMBER
• Enter the placement worker’s name and phone number in this section. (Refer the child’s file for this information.)
HOME VISITS (leaving)
This section should only be completed if applicable. Each time a child leaves on a home visit, the medications that are given to their authorized repre-
sentative should be logged and accounted for. Ensure that the authorized representative knows who to contact if an incident occurs during the visit.
DATE
• Enter the date that the medication was given to the authorized representative.
NAME OF MEDICATION
• Enter each individual medication that is being released for the home visit.
QUANTITY
• Enter the medication count (number of pills) that is being given to the authorized representative for the home visit.
INITIALS OF PERSON RELEASING MEDICATION
• This section should be initialed by the person releasing the medication to the authorized representative for the home visit.
RECEIVED BY
• This section should be signed by the authorized representative receiving the medication.
HOME VISITS (returning)
Each time a child returns from a home visit, the medications should being given back to the facility, logged, and accounted for.
DATE
• Enter the date that the authorized representative returned upon the end of the home visit.
NAME OF MEDICATION
• Enter each individual medication that has been returned after the home visit.
QUANTITY
• Enter the medication count (number of pills) that has been returned after the home visit.
INITIALS OF PERSON RECEIVING MEDICATION
• This section should be initialed by the person receiving the medication from the authorized representative after the home visit.
RELEASED BY
• This section should be signed by the authorized representative once they have returned the medication after the home visit.
MEDICATIONS NOT ADMINISTERED
DATE
• Enter the date that the medication was not self-administered as directed by the prescription.
HOUR
• Enter the time that the medication was not self-administered as directed by the prescription.
MEDICATION NAME
• Enter the name of the medication that was not self-administered as directed by the prescription.
REASON
• Explain the reason the medication was not self-administered as directed by the prescription.
RESULT
• Note any observed or reported behaviors or symptoms that may have resulted from the child’s missed medication, (For instance: child became
hyperactive, child became aggressive, child complained of a headache, etc.)
INITIALS
• Enter the initials of the caregiver/staff member who was supervising the child when the medication was missed.
STAFF SIGNATURE
• The caregiver/staff member who was supervising the child when the medication was missed will need to sign here.
LIC 622B (5/17)
PAGE 4 OF 4
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