Health Manager Orientation Guide

Health Record Management

An office with three people busy working on their computers at one large desk.The management of health records includes how programs organize, review, and respond to health information.

Health records may be hard-copy or electronic documents, files, and data. Documentation of health information and its review, response, follow-up, and communication are usually managed in the program's health tracking system. The system may be manual, such as a spreadsheet, or electronic, where information is entered into a shared database. Electronic tracking systems that have been designed specifically for Head Start health services are common methods for health tracking.

Tips and Strategies for Health Record Management

  • Identify the health records that will give the program enough health information to care for the child and to document evidence of services. These may include, but are not limited to:
    • Health history
    • Nutrition screening and assessment
    • Physical exam
    • Vision and hearing screenings
    • Dental exam and treatment
    • Other screenings according to the state, tribal, or territorial Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) guidelines
    • Medical treatment
    • Other accommodation forms (e.g., individual health care plan or medication forms)
    • Internal and external referrals
    • Communication with family, other Head Start staff, and health care providers, including follow-up on known or potential health concerns 
    • Other information or records according to the program's policies and procedures
  • Set up procedures and expectations for reviewing health records and responding to the information, including the staff who are responsible, timelines, actions, and processes for documenting.
  • Set up procedures with expectations for the staff's follow-up on known or suspected health concerns and overdue health information and services.
  • Set up a health tracking system that tracks these health activities:
    • Recommended and required health services
    • Timelines and reminders for upcoming services
    • Overdue health information or services
    • Results of health services, such as screenings and referrals
    • Follow-up efforts, strategies, and activities
    • Analysis and reporting of health information
  • Set up procedures that protect the confidentiality of children's personally identifiable information, including their health information, and how information is acquired, secured, and shared.
  • Make sure confidentiality procedures protect children and families according to:
  • Set up procedures for the maintenance and retention of health information, including:
    • Only parents or legal guardians, and officials in the program or acting on behalf of the program have access to the records.
    • Health records are properly destroyed in a reasonable timeframe when they are no longer needed or required to be maintained.