DOCUMENTATION GUIDELINES
Description of lesions; rashes; and any neurological, visual, or cardiac abnormalities
Reactions to medications, including the site and dosage of intramuscular (IM) injections
Information for follow-up, including report of disease incidence to the local health authority and names of patient contacts (to maintain confidentiality, this information may not be kept in the patient's treatment record)
Syphilis has been found in Diseases and Disorders
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