Children’s Health Records

Children’s Health Records “The health and safety of individual children requires that information regarding each child in care be kept and available when needed. Children’s records consist of various documentation such as a child’s medical and immunization history, emergency medical care information, and parental permission to participate in specific activities…Each child care facility must keep accurate records on each child receiving care in child care.”3 Health records can help early care and education programs identify preventative health measures, develop care plans for children with special needs, and determine whether or not a child should be excluded from care due to illness. Health record requirements differ from state to state and often use state-specific forms. Review the child care regulations for your state to ensure you know the requirements. The Caring for Our Children: National Health and Safety Standards recommend that the following be included in children’s health records:

 Immunization Records;

 Growth Assessment – may include percentiles of weight, height, and head circumference (under age of two); recording body mass index (BMI) and percentile for age is especially helpful in those children age two years and older who are over or underweight;

 Health Assessment – includes descriptions of any current acute and/or chronic health issues and should also include any findings from an exam or screening that may need follow-up, e.g., vision, hearing, dental, obesity, or nutritional screens or tests for lead, anemia, or tuberculosis (these health concerns may require a care plan and possibly a medication plan [see h) below]);

 Developmental Issues – includes descriptions of concerns and the child’s special needs in a child care setting, (for example, a vision or hearing deficit, a developmental variation, prematurity, or an emotional or behavioral disturbance);

 Significant physical findings so that caregivers/teachers can note if there are changes from baseline and report those findings;

 Dates of Significant Illnesses and/or Injuries;

 Allergies;

 Medication(s) List – includes dosage, time and frequency of administration of any ongoing prescription or non-prescription (over-the-counter [OTC]) medication that the person with prescriptive authority recommends for the child. This list would also include information on recognizing side-effects and responding to them appropriately and it may also contain the same information for intermittent use of a fever reducer medication;

 Dietary modifications;

 Emergency plans;

 Other special instructions for the caregiver/teacher;

 Care Plan – (if the child has a special health need) includes routine and emergency management plans that might be required by the child while in child care. This plan also includes specific instructions for caregiver/teacher observations, activities or services that differ from those required by typically developing children and should include specific instructions to caregivers/teachers on how to provide medications, procedures, or implement modifications required by children with asthma, severe allergic reactions, diabetes, medically-indicated special feedings, seizures, hearing impairments, vision problems, or any other condition that requires accommodation in child care;

 Parent’s/Guardian’s assessment and concerns

For children up the age of three years, health care professional assessments should be at the recommended intervals indicated by the American Academy of Pediatrics (AAP) (3). For all other children, the Health Care Professional Assessment updates should be obtained annually. It should include any significant health status changes, any new medications, any hospitalizations, and any new immunizations given since the previous health assessment. This health report will be supplemented by the health history obtained from the parents/guardians by the child care provider at enrollment.