9.4.1.9: Records of Injury

When an injury occurs in the facility that results in first aid or medical attention for a child or adult, the facility should complete a report form that provides the following information:

1. Name, sex, and age of the injured person;
2. Date and time of injury;
3. Location where injury took place;
4. Description of how the injury occurred, including who (name, address, and phone number) saw the incident and what they reported, as well as what was reported by the child;
5. Body part(s) involved;
6. Description of any consumer product involved;
7. Name and location of the staff member responsible for supervising the child at the time of the injury;
8. Actions taken by staff members on behalf of the injured following the injury as well as specifically whether emergency medical services and/or professional dental/medical care was required;
9. Recommendations of preventive strategies that could be taken to avoid future occurrences of this type of injury;
10. Name of person who completed the report;
11. Name, address, and phone number of the facility;
12. Signature of the parent/guardian of the child injured or signature of the adult injured and the date signature obtained (recommended that the signature be obtained the same day as the injury);
13. If parent/guardian of child was notified at time of injury;
14. Documentation that written report was sent home the day of the injury, regardless of parental signature.

Examples of injuries that should be documented include:

1. Child maltreatment (physical, sexual, emotional, and neglect abuse);
2. Bites that are continuous in nature, break the skin, left a mark, and cause significant pain;
3. Falls, burns, broken limbs, tooth loss, other injury;
4. Motor vehicle injury;
5. Aggressive/unusual behavior;
6. Ingestion of non-food substances;
7. Medication error;
8. Blows to the head;
9. Death.

Three copies of the injury report form should be completed. One copy should be given to the child’s parent/guardian (or to the injured adult). The second copy should be kept in the child’s (or adult’s) folder at the facility. A third copy should be kept in a chronologically filed injury log that is analyzed periodically to determine any patterns regarding time of day, equipment, location or supervision issues. This last copy should be kept in the facility for the period required by the state’s statute of limitations. If required by state regulations, a copy of an injury report for each injury that required medical attention should be sent to the state licensing agency.

Based on the logs, the facility should plan to take corrective action. Examples of corrective action include: adjusting schedules, removing or limiting the use of equipment, relocating equipment or furnishings, and/or increasing supervision.

RATIONALE

Injury patterns and child abuse and neglect can be discerned from such records and can be used to prevent future problems (1,2). Known data on typical injuries (scanning for hazards, providing direct supervision, etc.) can also how to prevent them. A report form is also necessary for providing information to the child’s parents/guardians and primary care provider and other appropriate health or state agencies.

COMMENTS

Caregivers/teachers should report specific products that may have played a role in the injury to the U.S. Consumer Product Safety Commission (CPSC) via their toll-free consumer hotline: 800-638-2772 (TTY 800-638-8270) or online at http://www.cpsc.gov/talk.html. This data helps CPSC respond with needed recalls. Multi-copy forms can be used to make copies of an injury report simultaneously for the child’s record, for the parent/guardian, for the folder that logs all injuries at the facility, and for the regulatory agency.

Facilities should secure the parent’s/guardian’s signature on the form at the time it is presented to the parent/guardian.

TYPE OF FACILITY

Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home

RELATED STANDARDS

9.2.4.1 Written Plan and Training for Handling Urgent Medical or Threatening Incidents
9.4.1.10 Documentation of Parent/Guardian Notification of Injury, Illness, or Death in Program
9.4.1.11 Review and Accessibility of Injury and Illness Reports
Appendix DD: Injury Report Form for Indoor and Outdoor Injuries
Appendix EE: America’s Playgrounds Safety Report Card
Appendix KK: Authorization for Emergency Medical/Dental Care
Appendix CC: Incident Report Form

REFERENCES

1. Murph, J. R., S. D. Palmer, D. Glassy, eds. 2005. Health in child care: A manual for health professionals. 4th ed. Elk Grove Village, IL: American Academy of Pediatrics.
2. ChildCare.net. Incident reports. http://www.childcare.net/library/incidentreports.shtml.