9.4.2.1: Contents of Child’s Records

The facility should maintain a file for each child in one central location within the facility. This file should be kept in a confidential manner but should be immediately available to the child’s caregivers/teachers (who should have parental/guardian consent for access to records), the child’s parents/guardians, and the licensing authority upon request.

The file for each child should include the following:

1. Pre-admission enrollment information;
2. Admission agreement signed by the parent/guardian at enrollment;
3. Initial health care professional assessment, completed and signed by the child’s primary care provider and based on the child’s most recent well care visit and containing a complete immunization record as recommended at http://www.aap.org/immunization/ and a statement of any special needs with a care plan for how the program should accommodate these special needs (this should be on file preferably at enrollment or a two week written plan should be provided upon admission);
4. Updated health care professional assessments should be completed from the initial assessment filed except that such assessments should be at the recommended intervals by the American Academy of Pediatrics (AAP) until the age of two years and annually thereafter;
5. Health history to be completed by the parent/guardian at admission, preferably with staff involvement;
6. Medication record, maintained on an ongoing basis by designated staff;
7. Authorization form for emergency medical care (see Appendix KK: Authorization for Emergency Medical/Dental Care for an example; this form should not be used for routine problems or when the parent can be reached);
8. Any written informed consent forms signed by the parent/guardian allowing the facility to share the child’s health records with other service providers.

RATIONALE

The health and safety of individual children requires that information regarding each child in care be kept and made available on a need-to-know basis. Prior informed, written consent of the parent/guardian is required for the release of records/information (verbal and written) to other service providers, including process for secondary release of records. Consent forms should be in the native language of the parents/guardians, whenever possible, and communicated to them in their normal mode of communication. Foreign language interpreters should be used whenever possible to inform parents/guardians about their confidentiality rights (1).

TYPE OF FACILITY

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

RELATED STANDARDS

9.4.1.3 Written Policy on Confidentiality of Records
9.4.2.4 Contents of Child’s Primary Care Provider’s Assessment
Appendix I: Recommendations for Preventive Pediatric Health Care
Appendix KK: Authorization for Emergency Medical/Dental Care

REFERENCES

1. American Academy of Pediatrics, Committee on Pediatric Emergency Medicine. 2007. Policy statement: Consent for emergency medical services for children and adolescents. Pediatrics 120:683-84.