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Mandatory Elements in Clinical Notes Documentation must include: Provider order Drug name, lot number, and expiration date Reason for injection Route and site Start and end times (if required) Proper Documentation of the Medication Administered Always document: NDC number Dosage Manufacturer Any patient reactions Dosage, Route, and Patient Response Recording Precise documentation protects against denials and audits

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REVIEW THE MEDICATION INVENTORY LOG A review of the current medication inventory log your office uses to track the purchase and dispensing of medications is best practice