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Get CA LIC 622 1999

Medication records on each client/resident shall be maintained for at least one year. NAME LAST MEDICATION NAME LIC 622 3/99 CONFIDENTIAL FIRST STRENGTH/ QUANTITY MIDDLE CONTROL/CUSTODY EXPIRATION DATE ADMISSION DATE FILLED STARTED ATTENDING PHYSICIAN PRESCRIBING PHYSICIAN ADMINISTRATOR PRESCRIPTION NO. STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF SOCIAL SERVICES COMMUNITY CARE LICENSING CENTRALLY STORED MEDICATION AND DESTRUCTION RECORD FACILITY NAME INSTRUCTIONS Centrally stored medications shall be kept in a safe and locked place that is not accessible to any person s except authorized individuals. OF NUMBER REFILLS NAME OF PHARMACY II. MEDICATION DESTRUCTION RECORD Designated Representative and witnessed by one other adult who is not a client/resident. All facilities except Residential Care Facilities for the Elderly RCFEs shall retain destruction records for at least one year. RCFEs shall retain records for at least three years. DATE FILLED PRESCRIPTION DISPOSAL NAME OF PHARMACY SIGNATURE OF ADMINISTRATOR OR DESIGNATED REPRESENTATIVE SIGNATURE OF WITNESS ADULT NON-CLIENT. OF NUMBER REFILLS NAME OF PHARMACY II. MEDICATION DESTRUCTION RECORD Designated Representative and witnessed by one other adult who is not a client/resident. All facilities except Residential Care Facilities for the Elderly RCFEs shall retain destruction records for at least one year. All facilities except Residential Care Facilities for the Elderly RCFEs shall retain destruction records for at least one year. RCFEs shall retain records for at least three years. DATE FILLED PRESCRIPTION DISPOSAL NAME OF PHARMACY SIGNATURE OF ADMINISTRATOR OR DESIGNATED REPRESENTATIVE SIGNATURE OF WITNESS ADULT NON-CLIENT. OF NUMBER REFILLS NAME OF PHARMACY II. MEDICATION DESTRUCTION RECORD Designated Representative and witnessed by one other adult who is not a client/resident. All facilities except Residential Care Facilities for the Elderly RCFEs shall retain destruction records for at least one year. RCFEs shall retain records for at least three years. DATE FILLED PRESCRIPTION DISPOSAL NAME OF PHARMACY SIGNATURE OF ADMINISTRATOR OR DESIGNATED REPRESENTATIVE SIGNATURE OF WITNESS ADULT NON-CLIENT. .

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