Caring for Our Children (CFOC)

Chapter 9: Administration

9.4 Records

9.4.2 Child Records Contents of Child’s Primary Care Provider’s Assessment

The file for each child should include an initial health assessment completed and signed by the child’s primary care provider. This should be on file preferably at enrollment and no later than within six weeks of admission. (Requirements may be waived to comply with the federal McKinney-Vento Homeless Assistance Act regarding health and health records.) It should include:

  1. Immunization Records;
  2. 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;
  3. 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]);
  4. 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);
  5. Significant physical findings so that caregivers/teachers can note if there are changes from baseline and report those findings;
  6. Dates of Significant Illnesses and/or Injuries;
  7. Allergies;
  8. 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;
  9. Dietary modifications;
  10. Emergency plans;
  11. Other special instructions for the caregiver/teacher;
  12. Care Plan – (if the child has a special health need as indicated by c) or d) above) 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;
  13. Parent’s/Guardian’s assessment and concerns (4).

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.

The requirement of a health report for each child reflecting completion of health assessments and immunizations is a valid way to ensure timely preventive care for children who might not otherwise receive it and can be used in decision-making at the time of admission and during ongoing care (2). This requirement encourages families to have a primary care provider (medical home) for each child where timely and periodic well-child evaluations are done. The objective of timely and periodic evaluations is to permit detection and treatment for improved oral, physical, mental, and emotional/social health (1,3). The reports of such evaluations provide a conduit for communication of information that helps the primary care provider and the caregiver/teacher determine appropriate services for the child. When the parent/guardian carries the request for the report to the primary care provider, concerns of the caregiver/teacher can be delivered by the parent/guardian to the child’s primary care provider and consent for communication is thereby given. The parent/guardian can give written consent for direct communication between the primary care provider and the caregiver/teacher so that the forms can be faxed or mailed.

Quality child care requires information about the child’s health status and need for accommodations in child care (2).

The purpose of a health care professional assessment is to:
  1. Give information about a child’s health history, special health care needs, and current health status to allow the caregiver/teacher to provide a safe setting and healthy experience for each child;
  2. Promote individual and collective health by fostering compliance with approved standards for health care assessments and immunizations;
  3. Document compliance with licensing standards;
  4. Serve as a means to ensure early detection of health problems and a guide to steps for remediation;
  5. Serve as a means to facilitate and encourage communication and learning about the child’s needs among caregivers/teachers, primary care providers, and parents/guardians.

This approach is usually the most efficient, effective and least costly since the primary care provider has the child, the family member, and the record in hand, to provide the information that the child care facility should have. When the data are requested separate from the visit to the primary care provider for the health assessment, the record must be pulled from the file and the information retrieved from the notes in the file. Some health care facilities charge families for the cost of the additional work to complete forms either at the time of a health care visit or later. Collaborating in reducing the burden of form completion by writing in as much information as is known before giving the forms to the primary care provider helps foster effective communication. Many primary care providers appreciate having identifying information filled in on the form about the child care facility, the child, the family and a note about any concerns to be addressed.

Caregivers/teachers may offer a four-week grace period during which the parent/guardian can arrange to get this assessment. The health history can serve as an interim health assessment during this grace period.

Health data should be presented in a form usable for caregivers/teachers to help identify any special needs for care. Local Early Periodic Screening and Diagnostic Treatment (EPSDT) program contractor, if available, should be called upon to help with liaison and education activities. In some situations, screenings may be performed at the facilities, but it is always preferable that the child have a medical home and primary care provider who screens the child and provides the information. When clinicians do not fill out forms completely enough to assist the caregiver/teacher in understanding the significance of health assessment findings or the unique characteristics of a child, the caregiver/teacher should obtain parental consent to contact the child’s primary care provider to explain why the information is needed and to request clarification.

Health assessments should be in a format easily usable by caregivers/teachers to identify any special needs for care.

A child’s primary care provider is a key resource to families when racial, ethnic, socioeconomic, or educational disparities create barriers to the child receiving regular dental care. He or she can perform an oral examination and conduct an oral health risk assessment and triage for infants and young children. Children with suspected oral problems should see a dentist immediately, regardless of age or interval.

The American Academy of Pediatrics (AAP) and Bright Futures recommend vision/hearing and dental screenings are:

  1. Vision/hearing at every well care visit (with objective measures of visual acuity by four years and audiometry measures of hearing by five years of age); and
  2. Dental exam at one year (or sooner if there are suspected oral problems) (3).
Center, Early Head Start, Head Start, Large Family Child Care Home, Small Family Child Care Home
RELATED STANDARDS Contents of Child’s Records Health History
Appendix FF: Child Health Assessment
Appendix O: Care Plan for Children with Special Health Care Needs
  1. Hagan, J. F., J. S. Shaw, P. M. Duncan, eds. 2008. Bright futures: Guidelines for health supervision of infants, children, and adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics.
  2. 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.
  3. American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine, Bright Futures Steering Committee. 2007. Policy statement: Recommendations for preventive pediatric health care. Pediatrics 120:1376.
  4. Crowley A. A., G. C. Whitney. 2005. Connecticut’s new comprehensive and universal early childhood health assessment form. J School Health 75:281-85.