Medicaid Services �

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���Nursing Services �How to document medical services on a Clinical Service Note for CGM?��2 - 8 - 2023��

Deitrich Drayton

Student Services Compliance Administrator

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Agenda

• Purpose of the Training
• Medical Forms
• Review Nursing Documentation – Clinical Service Notes
• Service Components
• Resources

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Purpose of the Medicaid Nursing Training

• Provide training to promote a greater understanding of the Nursing policies and procedures for the nursing program.

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• This training provides a brief overview of policy requirements specific to Nursing Services.

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• Schools are responsible for ensuring that nursing procedures are followed according to SCDE, DHEC, SCLLR guidelines, and the Nurse Practice ACT.

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Note: This is not a comprehensive nursing training session.

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Nursing Services for Children Under 21 Year

Nursing services for children under 21 years are those specialized health care services including:

• nursing assessment and nursing diagnosis
• direct care and treatment
• administration of medication and treatment as authorized and prescribed by a physician or dentist and/or other licensed/authorized healthcare provider
• nurse management
• health counseling and emergency care.

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An RN as allowed under state licensure and regulation must perform acts of nursing diagnosis or prescription of therapeutic or corrective measures. The need for services must be appropriately documented in an IEP, IFSP, IHP, or ITP or clinical service notes, when appropriate.

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Nursing Documentation

Nursing documents must be completed annually, and for new students entering school.

• Consent and Permission to Provide Medication or Medical Services
• General Medicaid Consent (for Medicaid students)
• Permission to Provide Medication (IDEA requirement)

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• Medical Orders (For all students with a medical prescription)
• Medical Assessment (For students with a medical prescription – nurse evaluation)
• Individualize Education Plan (IEP), Individual Health Plan (IHP), or Individual Treatment Plan (ITP) – (For students with a medical prescription)
• Clinical Service Notes (CSN) (Documentation for all students receiving medical care)
• Staff Credentials – (For all Nursing staff providing medical care)
• Storage and Retention of Records – (For medical records – FERPA and HIPAA regulations)

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Prescribers of Medical Orders

A medical order for prescriptions or treatment must be prescribed by one of the following:

• Medical Doctor (M.D.),
• Doctor of Osteopathy (D.O.),
• Dentist (D.M.D., D.D.S),
• Advanced Practice Registered Nurse (APRN), and
• Physician Assistant (PA).

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Medical Orders

A medical order is a written order by an authorized licensed prescriber for medication, treatment, or procedure; may also be referred to as a treatment order, medication permission form, or prescription.

Medical orders must be:

• given for prescriptions,
• written for treatments, and
• written medical procedures.

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Medical Orders - Documentation

The documentation must include:

• student name,
• date,
• addresses the frequency and duration of the order (i.e., 1 x PRN, or 1 TID)
• reason for the medical orders,
• description of services to be rendered,
• signed by the prescribing provider, and
• parent must sign.

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Student Emergency and Health Information Form

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Detailed Student Medical, Health, and History Consent Form

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Page 2 of the Student Medical, Health, and History Form

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Medication and Treatment Permission Form

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�Authorization for Non-Prescription Over-the-Counter Medication at School

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Nursing Services Provided in Schools

School-based health centers (SBHC) provide a variety of health services beyond the first aid treatment provided by a school nurse.

• Administration of immunizations to children in accordance with state immunization law,
• Medication assessment, monitoring, and/or administration,
• Interventions related to the IEP, IFSP, IHP, or ITP, and
• Nursing procedures required for specialized health care including, but not limited to, feeding, catheterization, respiratory care, ostomies, medical support systems, collecting, and/or performance of tests, other nursing procedures, and development of health care and emergency protocols.

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Nursing Assessments - Documentation

Nursing Assessments must include:

• medical health problems,
• list medications,
• list treatments,
• write medical procedures taken by the nurse and
• child development issues observed by the nurse/child’s response to treatment.

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Purpose of the Clinical Service Note (CSN)

• The purpose of these notes is to record the nature of the child’s treatment by capturing the services provided and summarizing the child’s participation in treatment.
• When a treatment plan is not developed, the nursing session must be captured in a clinical service note.
• The nursing encounter may be documented electronically or handwritten. If a nursing platform or software is utilized, the software company has developed a template with the required components needed for proper documentation.

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CSN Requirements

Clinical Service Notes must include a narrative summary of each treatment encounter and must justify the number of units billed.

Clinical Service Note requirements:

• Provide a pertinent clinical description of the activities that took place during the session,
• Student’s level of participation/response to treatment as it relates to stated goals listed in the treatment plan,
• Reflect the delivery of a specific billable service as identified in the physician’s order,
• Document the services rendered corresponding to the billing
• Date of service, Type of service rendered, and number of units billed,
• Individualized and student-specific with the student’s response to treatment
• Start and stop times, and
• Date signature and professional title of the provider delivering the service.

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�CSN–CGM Daily Medication Log��The log report can be submitted to CGM weekly or monthly.

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CSN-CGM Signature Page

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Instructions on how to file out the Medication Log - Example

• Add the School Name: LEA – School Name
• Month and Year: February 2023 - Date -Medication log: February 1, 2023, to February 28, 2023
• Student’s Name, School Name, and the Student’s DOB – Student’s Medicaid Number
• CPT Code: T1502 – Medication Administration
• Physician's Legal Name: Dr. Smith
• Diagnoses: ADHD – Attention Deficit Hyper Disorder - DX Code/ICD 10 – F90.0 (Diagnoses website: ICD10coded.com)
• Physician’s Order: –Information from the doctor’s medical order
• Medication: Ritalin
• Frequency: 1 x day at noon
• Units: 1
• Entries for each time medication is rendered
• Date, Start Time, End Time, Dosage, Initials, and Student’s Response to Medication
• Signature of the Nurse: RN or LPN ( print, sign, title, and initial)

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CSN-CGM Form filled �out

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CSN-CGM�Medical Visit Log

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Instructions - How to file out the Medical Visit log - Example

• Add the School Name: LEA – School Name
• Month and Year: February 2023 - Date -Medication log: February 1, 2023, to February 28, 2023
• Student’s Name, School Name, and the Student’s DOB – Student’s Medicaid Number

Entries for each time a medical encounter occurs

• Date, Start Time, End Time (2-2-23, 10:00 am to 10:15 am)
• Treatment the nurse provided (Checked the student’s temperature and temperature was 99.1. The student has a fever, and he is not feeling well. Checked vital signs and they are normal.)
• Document the student’s response to treatment: (The student was instructed to lie down and rest for 10 minutes and Tylenol 200mg was given as requested by the parent’s permission. Parent was called to pick up the student).
• DX Code/ICD 10 – R50.9 - See this website for more diagnoses (Diagnoses website: ICD10coded.com)
• RN/LPN – circle the title that applies and circle the procedure code (T1002)
• Nurse Initial – The nurse must initial in this placeholder
• Nurse Documentation – The nurse has the option to document medical concerns and procedures.
• Signature of the Nurse: RN or LPN ( print, sign, title, and initial)

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�Nursing Procedure Codes

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Medication Pill Count Sheet – Example

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�Nursing Supervision - Updates

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• Nursing Supervision requirements
• An LPN must be supervised at all times by an RN.
• RN must be physically present or accessible by phone/pager, and
• RN must be readily available (i.e., physically accessible to the individual being supervised within a certain response time based upon the medical history and condition of the beneficiary and competency of personnel).

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• On October 21, SCDE and DHHS sent an email to update the nursing supervision. Medicaid will not require the RN to co-sign the LPN’s clinical service notes.

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�Supervision (Cont.)

• The RN supervisor will provide the initial assessment of the child’s condition as appropriate and establish a plan of care based on the child’s medical condition in accordance with state licensure and regulation.
• If the LPN receives additional information regarding the child’s health condition after the initial assessment, the LPN will consult with the RN.
• Supervision by the RN of the LPN must be performed at a minimum of every 60 days via direct observation or review of clinical service notes. It is best practice to have written or electronic documentation of the RN’s supervision of the LPN. Nurses billing Medicaid must show proof of supervision.

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Staff Credential Verification Process

• Schools are required to check the credentials of all licensed staff through SCLLR to verify their license, which may exclude them from providing services. A copy of the nurse’s license must be submitted to the district office. An updated copy must be kept on file.
• Schools using a software company must notify the district office of any staff changes.
• The copy of the South Carolina nurse license can be found at the South Carolina Labor and Licensing Regulatory Authority at https://llr.sc.gov.
• Medicaid nurses must check the staff’s name on the OIG’s webpage twice a year and keep a copy on file.
• The link is located at the Office of the Inspector General Provider Exclusion Database: https://exclusions.oig.hhs.gov/.

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Family Educational Rights and Privacy ACT (FERPA)/Healthcare Insurance Portability and Accountability Act (HIPAA)

• All records must follow the HIPAA/FERPA security measures.
• All clinical records must be secured under lock and key and in locked cabinets.
• Signature logs of people who have accessed health records.
• All providers must grant access to SCPCSD, or its designees for the purpose to review and/or investigate and allow for copying and reproducing documents.
• Each school should have a retention policy. Staff should review the General Records Retention Schedules for School District Records, Subarticle 6 Student Records for additional information. The webpage is located at https://scdah.sc.gov/sites/scdah/files/Documents/Records%20Management%20(RM)/Schedules/genskedskldist.pdf.
• The SC Archives also have staff that will help a school set up a retention schedule.

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�Medicaid Clinical Records and Maintenance

Requirements for Clinical Records and Maintenance

• Each clinical entry must be typed or legibly handwritten in dark ink,
• Clinical records must be arranged logically,
• All clinical entries must be filed in the student’s clinical records, and
• Each entry must stand on its own and not include arrows, ditto marks, etc.
• Schools are required to maintain a clinical record on every student that is rendered services.
• Clinical records must be current, meet documentation requirements and provide a clear descriptive narrative of the services provided.
• It is essential that an internal records review be conducted to ensure that the services are medically necessary and appropriate both in quality and quantity, and that services are documented.

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Resources

• SCDE-OMS Webpage: Medicaid - South Carolina Department of Education - 01/19/2023 4:02 PM (sc.gov)
• SCDHHS: Local Education Agencies Provider Manual - Report (Vertical) (scdhhs.gov)
• SCDHEC Resources: DHEC-liaison-Victoria Ladd, MSN, RN - State School Nurse Consultant Division of Children's Health and Perinatal Services - S.C. Dept. of Health & Environmental Control - Office: (803) 898-2347 - Email: laddvj@dhec.sc.gov

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Contact Information�Deitrich (Dee) Drayton�ddrayton@sccharter.org�(803) 212-5482�

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