Form LIC 622a 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.


Download Form LIC 622a Medication Administration Record (MAR) - California

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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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