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Physician order: A signed order for nandrolone decanoate injection, specifying dose and route Diagnosis documentation: The covered ICD-10-CM diagnosis, with clinical narrative supporting medical necessity Administration record: Date, time, dose administered (in mg), route, site, and the name of the administering clinician Drug identification: The NDC of the product used, lot number, and expiration date Controlled substance log: Because nandrolone decanoate is DEA Schedule III, keep a dispensing log that meets DEA and state pharmacy board rules Monitoring note: Any follow-up observation the ordering clinician requires, particularly for ongoing anemia management Medicare’s claims retention rules mean these records must still be reachable if a post-payment audit lands
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