Form Dhcs 5078 - California C-6a Centrally Stored Medication And Destruction Record - Health And Human Services Agency

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State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
C-6A – CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD
Resident's Name:
Admission Date:
Attending Physician:
Facility Name:
Facility ID No.:
Program Director:
CENTRALLY STORED MEDICATION INSTRUCTIONS: Licit medications which are permitted by the licensee shall be controlled as specified by the
licensee's written goals, objectives and procedures.
Medication Name
Strength/
Instructions
Expiration
Date
Prescribing
Prescription
No.
Name of
Quantity
Control/Custody
Date
Filled
Physician
Number
Refills
Pharmacy
MEDICATION DESTRUCTION RECORD INSTRUCTIONS: Prescription drugs not taken with the resident upon termination of services or otherwise
disposed of shall be destroyed in the facility by the Program Director or designated representative and witnessed by one other authorized individual (NON-
RESIDENT).
Medication Name
Strength/
Date
Prescription
Disposal
Name of
Administrator's Signature
Witness' Signature
Quantity
Filled
Number
Date
Pharmacy
DHCS 5078 (07/13)

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