ABCDEFGHIJOPQRSTXYZAA
1
Medical Visit Log - LEA - School Name
2
Month/Year: ___________________
3
Dates: From _____________, 20___ to _____________, 20___
4
STUDENT's LEGAL NAME School Name
5
Medicaid Number
DOB:
6
List Student Medication Administration
7
DateStart TimeEnd TimeTreatment ProvidedStudent Response to Medical TreatmentDX Code:RN/LPN
Nurse Initials
8
T1002 T1003T1015
9
Nurse Documentation: Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
10
11
DateStart TimeEnd TimeTreatment ProvidedStudent Response to Medical TreatmentDX Code:RN/LPN
Nurse Initials
12
T1002 T1003T1015
13
Nurse Documentation: Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
14
15
DateStart TimeEnd TimeTreatment ProvidedStudent Response to Medical TreatmentDX Code:RN/LPN
Nurse Initials
16
T1002 T1003T1015
17
Nurse Documentation: Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
18
19
DateStart TimeEnd TimeTreatment ProvidedStudent Response to Medical TreatmentDX Code:RN/LPN
Nurse Initials
20
T1002 T1003T1015
21
Nurse Documentation: Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
22
23
DateStart TimeEnd TimeTreatment ProvidedStudent Response to Medical TreatmentDX Code:RN/LPN
Nurse Initials
24
T1002 T1003T1015
25
Nurse Documentation: Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
26
27
DateStart TimeEnd TimeTreatment ProvidedStudent Response to Medical TreatmentDX Code:RN/LPN
Nurse Initials
28
T1002 T1003T1015
29
Nurse Documentation: Note additional information about additional action taken, observations, contact with school nurse and/or parent to report problems and outcome.
30
31
32
Service Provider's Printed Legal NameService Provider's Signature Legal NameLegible Title (RN, LPN)
33
34
35
36
Supervising RN's Printed Legal Name (if applicable):
37
38
"I authorize the release of any medical or other information necessary for CGM, Inc. to process these claims. Signature is on file." _____RN Initials
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100