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A compliant medical record should generally include: Chief complaint Diagnosis supporting treatment Medication name Drug strength Dose administered Route of administration (SC or IM) Injection site when clinically appropriate Ordering provider Individual administering the injection Date of service Patient response when medically relevant If the practice supplies the medication, documentation should also support the HCPCS drug code and the number of units billed

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[DOI] [PubMed] [Google Scholar] 145.Wolozin B