|
Allergies:
|
Medical History:
|
|
IM Injection requested:
• • •
|
Area of Injection
• • •
|
|
Skin asessment prior to injection:
|
Education given:
• • •
|
|
Misc education
|
Patient Tolerated well prodecure?
|
|
Notes:
|
Notes (Reserved only if pte did not tolerate)
|
|
RN:
|
|
