Health Manager Orientation Guide

Identification, Communication, and Documentation of Medications

Two women reviewing notes.The identification of children with known or suspected medication needs can ensure timely enrollment, minimize interruptions in attendance, and support how they fully participate in and benefit from Head Start programs and services.

The family is usually the place to start when communicating about known or suspected medication needs and developing Individual Health Care Plans (IHPs). Talking with the family can help a program’s health services staff learn more about their skills and self-sufficiency related to their child’s medication needs. This helps the program identify barriers or connect the family with needed supports. Individualized health care planning also includes instructions and information from the child’s health care professionals. Ongoing, three-way communication among the family, Head Start staff, and health care professionals is essential. The American Academy of Pediatrics describes this as a Family-centered Medical Home approach, where families are recognized as the child’s primary caregiver and are essential partners in their child’s health care planning.

Comprehensive documentation procedures then support effective identification and communication and may include one or more of these documents and processes:

  • Parent or guardian consent form
  • Health care professional instructions
  • Medication administration record or log
  • Forms required by a program’s state, tribal, and territorial regulations
  • Other medical documents (e.g., physical exam or assessment form, health history or intake, more information specific to the health need or medications)
  • Medication procedures checklist
  • IHP

Tips and Strategies for Identification, Communication, and Documentation of Medications

  • Set up procedures that help staff:
    • Identify medication needs early in the enrollment process.
    • Communicate about medication needs throughout the program year, such when the family or health care professional has new information.
  • Give staff the medication documents or forms that will be included in the program’s medication procedures.
  • Identify expectations for acceptable parent or legal guardian consent, and health care professional documentation and instructions that align with your program’s state, tribal, and territorial regulations.
  • At a minimum, documentation usually includes:
    • Name of the medication
    • Diagnosis or medication condition that is being treated
    • Dosage, route, frequency, length of time the medication should be given
    • Any other instructions
  • Forms of documentation may include one or more of these:
    • Completed medication authorization form
    • Head Start physical exam form
    • Referral or consultation documents
    • Prescription label
  • Set up procedures for recording the administration of medications, including:
    • Type and amount of medication
    • Date and time medication was given
    • Staff (name and title) who administered the medication
    • Reasons or symptoms that prompted staff to administer an emergency medication or a medication that is given only as needed
    • Possible side effects
    • Details supporting why a medication was not given, including absent child, spilled dose, child’s refusal to take medication, or spit-out or vomited doses
  • Use separate medication administration documents for each medication, including children who take more than one medication.
  • Update medication documents at least annually, or more often if the medications or administration instructions change.