Form LIC622b "Psychotropic Medication Administration Record (MAR)" - California

What Is Form LIC622b?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2017;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LIC622b by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form LIC622b "Psychotropic Medication Administration Record (MAR)" - California

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
PSYCHOTROPIC MEDICATION ADMINISTRATION RECORD (MAR)
NOTE: Fill out a separate LIC 622B for each psychotropic medication the child is currently taking (HSC§ 1507.6[b][2][B].
Child’s Name:
JV223 Date:
Date of Birth:
Sex:
Facility Name & Number or Foster/Certified/Resource Family Agency Name:
MO/YR:
Prescription Details
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Allergies:
Additional Instructions From Physician:
Date of Last Lab:
Anticipated Refill Date:
Date and Description Of Any Observed Side Effects:
Pharmacy Name & Number:
Physician Name & Number:
Monthly Weight & Date:
A.
Fill in what time the child takes the medication.
B.
Put initials in appropriate box when medication is given.
C.
Circle initials when not given.
Placement Worker Name & Number:
D.
State reason for refusal / omission on page 2 of 2.
E.
S = School; H = Home visit; W = Work; P = Program; R = Refusal; O = Other.
HOME VISITS (Leaving)
HOME VISITS (Returning)
Initials of
Initials of
Signature of Authorized
Signature of Authorized
Person
Person
Date
Name Of Medication
Quantity
Representative Receiving
Date
Name Of Medication
Quantity
Representative
Releasing
Receiving
Medication
Releasing Medication
Medication
Medication
LIC 622B (5/17)
PAGE 1 OF 4
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
PSYCHOTROPIC MEDICATION ADMINISTRATION RECORD (MAR)
NOTE: Fill out a separate LIC 622B for each psychotropic medication the child is currently taking (HSC§ 1507.6[b][2][B].
Child’s Name:
JV223 Date:
Date of Birth:
Sex:
Facility Name & Number or Foster/Certified/Resource Family Agency Name:
MO/YR:
Prescription Details
Time
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Allergies:
Additional Instructions From Physician:
Date of Last Lab:
Anticipated Refill Date:
Date and Description Of Any Observed Side Effects:
Pharmacy Name & Number:
Physician Name & Number:
Monthly Weight & Date:
A.
Fill in what time the child takes the medication.
B.
Put initials in appropriate box when medication is given.
C.
Circle initials when not given.
Placement Worker Name & Number:
D.
State reason for refusal / omission on page 2 of 2.
E.
S = School; H = Home visit; W = Work; P = Program; R = Refusal; O = Other.
HOME VISITS (Leaving)
HOME VISITS (Returning)
Initials of
Initials of
Signature of Authorized
Signature of Authorized
Person
Person
Date
Name Of Medication
Quantity
Representative Receiving
Date
Name Of Medication
Quantity
Representative
Releasing
Receiving
Medication
Releasing Medication
Medication
Medication
LIC 622B (5/17)
PAGE 1 OF 4
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
1
2
3
4
5
6
7
8
9
10
11
Name:
MO / YR:
All Staff/Caregivers please sign and initial below in order to identify initials.
Signature
Initials
Signature
Initials
Signature
Initials
LIC 622B (5/17)
PAGE 2 OF 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
INSTRUCTIONS FOR LIC 622B – PSYCHOTROPIC MEDICATION
ADMINISTRATION RECORD (MAR)
Record onto the MAR immediately after each medication is self-administered by the child. This is the only way to be sure that the right
medication was taken, by the right person, at the right time, by the right route. Refer to the MAR Legend for additional instructions with this
form.
Psychotropic medications shall be used only in accordance with the written directions of the physician prescribing the medication and as
authorized by the juvenile court pursuant to Section 369.5 or 739.5 of the Welfare and Institutions Code (1507.6 (b)(1)).
CHILD’S NAME
• Enter the full name of the child that will be taking the medication.
JV-223 DATE
• This is the date in which the Court orders that the application requesting authorization to begin or continue taking psychotropic medication has
been granted. (This date can be found on page 2 of the Order Regarding Application for Psychotropic Medication (JV-223)).
DATE OF BIRTH
• Enter the child’s date of birth.
SEX
• Enter the biological sex (at birth) of the child that is listed in their file.
FACILITY NAME & NUMBER OR FOSTER/CERTIFIED/RESOURCE FAMILY AGENCY NAME
• Enter the name of the Licensed Community Care facility or home in which the child resides.
MO/YR
• Enter the month and year that this information in this log was documented.
PRESCRIPTION DETAILS
• Information for this section can be found on the label of the child’s medication.
• This section is required to be filled out pursuant to Health and Safety Code section 1507.6(b)(2)(B)(i)-(vi).
TIME
• In the “Time” column should be the hour that the medication is to be taken. The numbers in the top row of this table reflect the days of the month.
The adult filling out this MAR shall initial each box that corresponds with the appropriate date and time a child self-administers their medication. If
a medication is not taken as prescribed for any reason, follow the instructions in the MAR Legend. Notify the appropriate person(s) of the missed
medication according to your facility’s or agency’s policies.
ALLERGIES
• If the child is allergic to food, medication, etc., enter that information here.
ADDITIONAL INSTRUCTIONS FROM PHYSICIAN
• Refer to the child’s prescription for this information.
DATE OF LAST LAB
• Information for this section may need to be obtained from the prescribing physician.
ANTICIPATED REFILL DATE
• Information for this section can be determined by monitoring the number in the Quantity Prescribed section and the date that the child first began
taking the medication. The facility or agency should have a policy in place to ensure timely requests for refills.
• Enter the date in which this medication will need to be refilled.
DATE AND DESCRIPTION OF ANY OBSERVED SIDE EFFECTS
• It is a best practice to monitor and document the children’s reactions to their medication. If the child reports that he/she is experiencing side
effects from a medication or if staff observes side effects or changes in behavior, staff should document the reported or observed side effects in
this section.
PHARMACY NAME & NUMBER
• Enter the pharmacy’s name and phone number. (This can be found on the pharmacy label of the medication.)
PHYSICIAN NAME & NUMBER
• Enter the prescribing physician’s name and phone number in this section.
MONTHLY WEIGHT & DATE
• It is a best practice to monitor and document the child’s weight on a monthly basis. A child’s weight may significantly fluctuate while taking
psychotropic medication. Enter the child’s weight in this section and the date that the weight was taken.
LIC 622B (5/17)
PAGE 3 OF 4
STATE 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