Documentation in Childcare

A standard requirement for a child attending a childcare program is to have an application form on file. Along with the basic information about both child and parents, the form should include the child's medical history (including immunization records), medications taken and/or treatments needed, allergies, diet restrictions, and the name and contact information for the child's physician. Forms for special-needs children should also have a record of special services or therapies needed and case manager information.

Medications

It is very common for parents to give caregivers a child's medications that need to be administered during the day. There are many rules to follow when dispensing medication to children in your care. For instance, make sure all medication is brought in the original container and do not accept medications prepared for administration by the parents (e.g., filled syringes or pills in a baggie). But what type of documentation do you need? Be sure the parents have given you--in writing--the purpose for each medication and the most effective method of administration. You do not want to try to second-guess why a child is receiving certain drugs and may need to know this information in the event of an emergency.

For your protection, it is recommended that you have a signed copy of the original prescription on file so that you can read the directions. The prescription as written by the child's physician is important, as the directions provided by the pharmacist could be inaccurate or may not take into consideration other conditions or treatments for that particular child. Even the instructions provided by the child's parent may be misinterpreted from what the physician recommended. If the prescription or treatment is for an ongoing condition, it should be updated every 60 days to ensure that it is still needed. With over-the-counter (OTC) drugs, a written statement of need and dosage from the child's physician should be kept on file.

Treatments

Occasionally a childcare provider will have responsibility for administering treatments to children in their care. You may have to deal with breathing treatments, physical therapy exercises, maintenance of feeding tubes, or the care of children who have had colostomies. The general guideline is that every treatment and who provided it should be carefully documented in the child's record. At the end of the day, the parents should review and initial the record of all treatments administered to their child.

Outside Specialists

Children with special needs often have treatments or therapy provided in your childcare program by an outside professional. Visiting health care workers might include physical or occupational therapists, speech therapists, nurses, vision specialists, etc. While each of these professionals will be responsible for his or her own documentation, it is important for the childcare provider to have a clear record of who visited and worked with each child each day.

Does it matter who has the responsibility for giving the medications/treatments in your childcare program? In a large childcare facility the director, assistant director, or nurse would be the logical selection. In smaller programs or family childcare settings, responsibility might fall to just one person, or whoever is available. While it is wise to have particular staff designated for these tasks to ensure consistency, the most important criteria for the decision is to make sure the individual administering the medications or treatments is properly trained and double checks the name and dosage, then measures and administers it correctly. Training for these procedures is available in most communities through local public health agencies.

How should the above information be documented? The most common practice is to create a form for each child that includes spaces for the date, medication or treatment provided, amount given, method of administration, time given, name or initials of the caregiver who provided the treatment, and a space for the parents to initial at the end of the day. Yes, this means that every day that you give medication or a treatment to a child you should discuss this with the parent(s) and have them initial the form. Having parents initial the child's form daily will help everyone stay accurate and prevent the unnecessary administration of medication or treatment. This also may help protect the childcare provider from liability should improper treatments or medications harm the child. In lieu of a formal form, a simple notebook can be used to keep track of this information.

In an emergency situation where an unscheduled treatment or medication needs to be administered be sure to contact the parents immediately (preferably before the treatment is performed). Document it as you would any other first aid emergency and have the parents initial it when they pick up the child at the end of the day.

There are some excellent forms available for the purpose of documenting all of this information if you do not want to take the time to create your own. Most state agencies that regulate childcare facilities have basic forms available.

Model Child Care Health Policies, National Association for the Education of Young Children (NAEYC), 800-424-2460; www.naeyc.org

These websites offer downloadable forms:

www.childhealthonline.org

www.geocities.com/bbdc_1995/dc/forms.html

www.geocities.com/janalyn686/forms.html

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