injection
As an RN, I was taught all of the following would need to be documented.
Date,time,type of injection and medicine given, site given, patient response and education given and signature. Of course you would also want to make sure there is an order. An entry might read
1/8/09 1400 25mg toradol IM LLQ lt hip, tolerated well, instructed to stay 15 minutes with no driving, may cause drowsiness, dizziness. MSMITH RN
This would cover both the billing of the injection and what is required for the safety of the patient and your practices liability.
We have noticed alot of offices that we audit are not documented lab draws or injections appropriately.
Hope this helps.