School Based Nursing Services Definition
                            School-Based  Nursing  Services  are  face-to-face 
                             skilled  nursing  services  that  enable  a  Medicaid 
                             member           to       receive         medical         monitoring, 
                             interventions,         and  nursing  services  in  their 
                             educational setting. 
                            Please see Appendix 538A – Nursing Billing Form 
             Plan of Care Documentation
              Date of service
              Start and stop time
              Location of Service 
              Physician, PA or APRN order for the evaluation
              Purpose of evaluation
              Evaluator’s signature with credentials
              Presenting problem
              Duration and frequency of symptoms
              Members diagnosis per current International Classification 
               of Diseases (ICD) methodology
              Medicaid Member’s prognosis and rationale
              Rationale for diagnosis
              Appropriate recommendations consistent with the findings 
               of the evaluation 
             Nursing Services Documentation
             School-Based Nursing Services are face-to-face skilled 
              nursing services that enable a Medicaid member to 
              receive medical monitoring, interventions, and nursing 
              services in their educational setting. Please see Nursing 
              Billing Form. 
             Date of service 
             Start and stop times
             Location of service
             Nurse’s signature with credentials 
             Member’s Plan of Care (POC)
             Documentation of individual service
             If telehealth is utilized documentation must reflect such
             Appropriate recommendations consistent with the 
              findings of the assessment/evaluation.
                           Anaphylactic Reaction – Assessment/Evaluation 
                           Documentation must contain the following and be 
                           completed within 20 calendar days from the date of 
                           service: 
                              Date of service
                              Location of service
                              Nurse’s signature with credentials
                              Member’s Plan of Care (POC)
                              If telehealth is utilized documentation must reflect such
                              Appropriate recommendations consistent with the 
                               findings of the assessment/evaluation 
                           Anaphylactic Reaction – Individual 
                           Documentation must contain the following and be 
                           completed within 20 calendar days from the date of 
                           service: 
                              Date of service
                              Start and stop times
                              Location of service
                              Nurse’s signature with credentials
                              Member’s POC
                              Documentation of individual service
                              Appropriate recommendations consistent with the 
                               findings of the individual service