Form LIC622a "Medication Administration Record (MAR)" - California

What Is Form LIC 622A?

Form LIC 622A, Medication Administration Record (MAR) - also referred to as a MAR template - is a document used to record and administer medications prescribed to a child. This specific form is suitable to record non-psychotropic medications only. It is considered a legal record of the medications administered to a child by the health care professional.

The LIC 622A Form is a state-specific document issued and used by the California Department of Social Services Community Care Licensing Division. The most recent version of the form was released by the department in June 2017. You can find and download the up-to-date form through the link below.

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Community Care Licensing Medication Administration Record

The LIC medication administration record contains four pages in total. The first two are the form itself, the rest include detailed filing instructions. The MAR is a convenient way to ensure that the "six rights" are followed: the right dose of the right medication was taken by the right patient at the right time by the right route and the right documentation was made by licensed health care staff.

  1. The form is filled out by an adult supervising the child (a staff member or a caregiver);
  2. The document must contain the information about the child including name, date of birth, sex, and address;
  3. The separate form is filled out for each month of the treatment. Each form must contain the month and the year;
  4. The staff or caregiver filling out the form must indicate prescription details for all the non-psychotropic medications the child takes. This information is indicated on the label of the prescribed medications;
  5. The health care staff or caregiver must make an entry on this form immediately after each medication was taken by the child;
  6. When medication is given to the child, the health care staff or caregivers supervising the child enter their initials in the chart. If the medication is not administered, the initials should be circled;
  7. If any side effects are observed or reported, they must be entered on the form;
  8. Each time the prescribed medication is not administered, the health care staff or caregiver must record the details about the missed medication, reasons it was not taken, any observed or reported results on the corresponding chart on page 2. Besides, the health care staff supervising the child when the medication was missed must provide their initials and signature;
  9. All the staff and caregivers supervising the child must sign and provide their initials in table 3 on page 2 for identification purposes.

After the form is fully completed, it becomes a part of a patient's permanent record.

Besides Form LIC 622A there are two more MARs distributed by the Community Care Licensing Division (CCLD):

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Download Form LIC622a "Medication Administration Record (MAR)" - California

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CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
MEDICATION ADMINISTRATION RECORD (MAR)
NOTE: This form should be used for all non-psychotropic medication.
Child’s Name:
Date of Birth:
Sex:
Facility Name & Number or Foster/Certified/Resource Family Agency Name:
MO/YR:
Prescription Details
Time
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Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Allergies:
Date and Description of Any Observed Side Effects:
Monthly Weight & Date:
Anticipated Refill Date:
.
Pharmacy Name & Number:
Physician Name & Number:
A
Fill in what time the child takes the medication in the “TIME” column.
B.
Put initials in appropriate box when medication is given.
C.
Circle initials when not given.
Additional Instructions From Physician:
D.
State reason for refusal / omission on page 2 of 2.
E.
PRN Medications: Reason given and results must be noted on page 2 of 2.
Placement Worker Name & Number:
F.
S = School; H = Home visit; W = Work; P = Program; R = Refusal; O = Other
LIC 622A (6/17)
PAGE 1 OF 4
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
MEDICATION ADMINISTRATION RECORD (MAR)
NOTE: This form should be used for all non-psychotropic medication.
Child’s Name:
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
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18
19
20
21
22
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28
29
30
31
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Medication Name:
Required Dosage:
Time & Frequency of Dose:
Quantity Prescribed:
Prescription Filled Date:
Prescription #:
# of Refills:
Allergies:
Date and Description of Any Observed Side Effects:
Monthly Weight & Date:
Anticipated Refill Date:
.
Pharmacy Name & Number:
Physician Name & Number:
A
Fill in what time the child takes the medication in the “TIME” column.
B.
Put initials in appropriate box when medication is given.
C.
Circle initials when not given.
Additional Instructions From Physician:
D.
State reason for refusal / omission on page 2 of 2.
E.
PRN Medications: Reason given and results must be noted on page 2 of 2.
Placement Worker Name & Number:
F.
S = School; H = Home visit; W = Work; P = Program; R = Refusal; O = Other
LIC 622A (6/17)
PAGE 1 OF 4
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
COMMUNITY CARE LICENSING
MEDICATIONS NOT ADMINISTERED
Initials
Staff Signature
Date
Hour
Medication Name
Reason
Result
1
2
3
4
5
6
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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 622A (6/17)
PAGE 2 OF4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
INSTRUCTIONS FOR LIC 622A – 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.
CHILD’S NAME
• Enter the full name of the child that will be taking the medication.
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 the 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
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.
MONTHLY WEIGHT & DATE
• It is a best practice to monitor and document the child’s weight on a monthly basis. Enter the child’s weight in this section and the date that the
weight was taken.
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
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.
ADDITIONAL INSTRUCTIONS FROM PHYSICIAN
• Refer to the child’s prescription for this information.
PLACEMENT WORKER NAME & NUMBER
• Enter the placement worker’s name and phone number in this section. (Refer the child’s file for this information.
LIC 622A (6/17)
PAGE 3 OF 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING
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 622A (6/17)
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