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Heres what to include: Drug name, strength, and dosage Route of administration (IM or SQ) Injection site Medical necessity and diagnosis Name and credentials of the person administering it Avoid using generic notes such as gave injection. Instead, document: Administered 60 mg Toradol IM to left gluteal region due to acute migraine flare unresponsive to oral medication. This transparency drives both approvals and protects against audits

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