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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

Was the second injection site any where near the first site

If the patient is suspected to be sensitive to cobalt or other components of cobalamin, an intradermal test dose is recommended

These should specify the required refrigeration temperature (usually 36 to 46 degrees Fahrenheit, or 2 to 8 degrees Celsius) and any room temperature allowances

Many people feel better within a few weeks and continue gaining strength over several months with proper treatment