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The clinical record should include: Diabetes diagnosis or acute hyperglycemia event, such as E11.00, with supporting lab values (e.g., blood glucose level) The specific insulin product administered, lot number, and NDC The exact dose in units (not just insulin administered) Route of administration (subcutaneous injection or IV, as applicable) Name and credentials of the administering clinician Date, time, and location of administration Supporting patient compliance with insulin regimens through structured documentation also creates a longitudinal record that strengthens medical necessity across multiple visits