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Module 4.2 Documenting Health Observations

Learning Objectives

By the end of this module, you should be able to:

  • Summarize what goes into child health records.

Children’s Health Records                   

Health records can help early learning and childcare programs identify preventative health measures, develop care plans for children with special health needs, and determine whether a child should be excluded from care due to illness.

A close up view of files in a filing cabinet.
Figure 1 – Keeping health records for children is important. (Image is in the public domain)
LICENSING REQUIREMENTS: O. Reg. 137/15: GENERAL

72. (1) Every licensee shall ensure that up-to-date records are kept of the following matters in respect of each child receiving child care at a child care centre operated by the licensee or receiving child care at a premises where it oversees the provision of home child care:

Any symptoms indicative of ill health.

Written Records

Well-written and detailed notes can provide parents/guardians and physicians with valuable information that can help them make the correct diagnosis. Simply noting that child “wasn’t feeling well” is too vague. Written records should attempt to answer as many of the following questions as possible.

  • How has the child’s behavior changed to lead you to believe that the child may be ill?
  • What are the signs and symptoms the child is experiencing?
  • Is the child able to describe where pain/discomfort is located and whether it moves?
  • Is the pain/discomfort constant or does it come and go?
  • Is the child nauseated?
  • What has the child eaten and when?
  • How long has the child been displaying symptoms?
  • Is the child having difficulty urinating or having a bowel movement?
  • Has the child displayed similar symptoms previously?
  • What have you done for the child to help alleviate symptoms?
  • Are any other children in the program ill? (Do not identify individual children)

(Adapted from Pimento, B., Kernested, D. (2015)

 Important Things to Remember

  • It is a licensing regulation to keep up to date health records for each child in care to maintain licencing for the centre.
  • Program policies and procedures will identify this requirement for families and staff.

References

  1. Child Care Licensing Manual (2019). https://www.ontario.ca/page/child-care-centre-licensing-manual
  2. O.Reg. 137/15: GENERAL. https://www.ontario.ca/laws/regulation/150137#BK46
  3. Pimento, B., Kernested, D. (2015). Healthy Foundations in Early Childhood Settings, Fifth Edition. Toronto: Nelson.

License

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Health, Safety and Nutrition in Canadian Early Learning Environments Copyright © 2023 by Loyalist College is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License, except where otherwise noted.

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