Long-Acting Injectable Antipsychotic Administration Procedure Note

Date/Time of Administration: [Date and time of injection]

Location: [Clinic/facility and room/area]

Administering Clinician: [Name, credentials]

Patient Name: [Legal name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Indication and Regimen Context

[Primary diagnosis]; [initiation / maintenance / restart after missed dose / dose change]; [intended dosing interval]. Last injection: [date and site if verified / "unable to confirm; sources checked: pharmacy record, EHR MAR, patient report"]. (Keep to 1–3 lines. Do not infer dates, adherence, or injection site.)

Pre-Administration Verification

• Order verified (medication, dose, interval, route)
• Allergies reviewed: [allergy status or pertinent allergens]
• Two-patient-identifier verification performed: [identifiers used]
• Injection site assessed: [skin intact, no infection / findings if abnormal]
• Consent confirmed: [verbal consent / consent on file]. (For initiation encounters, note that risks/benefits were discussed.)

[Baseline vitals if obtained: BP, HR, RR, Temp, SpO₂, weight] (Include only if measured or required by protocol.)

(If injection was not given, omit remaining sections and document: [Not administered due to: reason; actions taken; prescriber notified; follow-up plan].)

Medication Administered

Medication: [Generic name (brand if helpful)]

Dose: [mg administered and volume in mL]

Route: [IM / deep IM per product requirements]

Site: [Left deltoid / Right deltoid / Left ventrogluteal / Right ventrogluteal] (Never infer site or laterality.)

Lot/Expiration: [Lot number and expiration date / "not captured in workflow"]

[Reconstituted per manufacturer instructions; appearance checked.] (Include only if product required reconstitution.)

Administration

Medication administered using aseptic technique. [Brief statement confirming injection completed without complication.]

[Deviation or complication if any: what occurred; actions taken; prescriber notified; safety report filed.] (Include only if applicable.)

Tolerance and Response

• Overall tolerance: [tolerated well / mild discomfort / moderate discomfort / poor tolerance]; [supporting detail]
• Injection site: [pain level]; [no adverse findings / bleeding / hematoma / redness / swelling]
• Systemic symptoms: [none / dizziness / sedation / confusion / anxiety / allergic symptoms / EPS / nausea]. [Patient quote if clinically significant]
• Interventions: [none / pressure applied / positioning / hydration / medications / escalation]

Post-Injection Monitoring

Observed [duration] in clinic; [no acute adverse effects; patient stable for discharge / findings if abnormal].

(For olanzapine pamoate [Zyprexa Relprevv], complete all items below as required:)

• Monitoring start time: [HH:MM]; end time: [HH:MM]
• Mental status checks: [times and findings; alert and oriented]
• Discharge readiness criteria met
• Escort confirmed: [name/relationship]; patient counseled not to drive or operate heavy machinery for remainder of day

[If patient refused monitoring or left early: capacity assessed; risks explained; prescriber notified; patient's transport plan; return precautions given.] (Include only if applicable.)

Patient Instructions

• Expected local reactions and care instructions provided
• When to seek urgent care: severe sedation, allergic symptoms, syncope, worsening site reaction
• Medication Guide provided [if required by product labeling]

Follow-Up

Next Dose Due: [Date based on product interval]

Next Appointment: [Date/time / to be scheduled within scheduling window]

Prescriber Follow-Up: [Psychiatry appointment date / earlier follow-up if adverse effects noted]

[Medication list or adverse reaction record updated.] (Include only if a new adverse reaction occurred.)

Signature

[Administering clinician name, credentials, date/time]

[Cosignature if required by facility policy]