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Heres what to include in your documentation: Drug name and dose Route of administration (IM or subcutaneous) Injection site (like right deltoid, left glute) Time given Who gave the injection Patient reaction or tolerance (especially if its a new med) Medical necessity (a quick blurb on why the injection was needed) If youre using electronic health records (EHR) then create a template to simplify this

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Confirm other causes are excluded (food allergy, mastocytosis, other GI disease)

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