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6.3.29.2 Documentation
Providers must document the following information in the client's medical record, which is subject to retrospective review to determine appropriate utilization and reimbursement of this service.
• The vaccine or toxoid given
•The date of the vaccine or toxoid administration (day, month, year)
•The name of the vaccine or toxoid manufacturer and the vaccine or toxoid lot number
•The signature and title of the person administering the vaccine or toxoid
•The organization and address of the clinic location
•The publication date of the VIS issued to the client, parent, or guardian
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