Reviewing Health Records [A Learning Activity]

In Head Start programs, reviewing health screening and examination results is a key to determining what a child's health needs are for treatment and followup. Health managers, disabilities coordinators, and program staff may use this learning activity to practice reviewing screening and exam results, determining appropriate follow-up, and discussing these plans with parents and staff. Requiring 30 to 60 minutes to complete, this activity utilizes handouts, which are included here.

The following is an excerpt from Well-Child Care: Making It Happen.

Purpose
For This Activity You Will Need
Trainer Preparation Note
Steps
Points to Consider
Handout: Child Health Record Samples
Handout: Well-Child Health Care Fact Sheets
Handout: Blank Records and Forms

Reviewing Health Records

Purpose: This activity allows participants to practice reviewing screening and exam results. They will work in teams to review a health record, determine the follow-up needed, and discuss the results and follow-up plans with parents and staff.

For this activity you will need:

Trainer Preparation Note:

  • Make a copy and an overhead transparency of the Child Health Record [PDF, 2.70MB]. If you want to update the child health records so that they reflect current information and have current dates, you will find blank copies of these handouts that you can fill out in [Handout]: Blank Records & Forms [PDF, 413KB].
  • Separate the Child Health Record Samples [PDF, 326KB] into Parts 1, 2, 3, 4, and 5.
  • Attach to each part the corresponding Fact Sheet(s) ...:
    • Part 1-Medical/Physical Exam, Growth
    • Part 2-Anemia, Lead, Tuberculin, Hearing, Vision, Immunizations
    • Part 3-Developmental
    • Part 4-Dental
    • Part 5-Nutrition
  • Write the questions from Step 4 on flip chart paper.

Step 1: Explain that this activity will give participants a chance to review screening and exam results and determine what follow-up is needed.

Step 2: Divide participants into five groups. Have each group identify a "recorder" to report back to the larger group.

Step 3: Ask participants to imagine they are the health coordinators responsible for reviewing health records and documenting and following up results for Janine, who is entering your Head Start program. Imagine that it is now September of the current year.

Step 4: Distribute one part of the Health Record and corresponding Fact Sheet(s) to each group.

Explain that each group has received a part of Janine's health record. Each group should take about 10 minutes to review its part of the record and discuss the following questions (posted on flip chart paper):

  • Is this part of the record complete? What, if anything, is missing?
  • Are the child's screening or exam results inside or outside of the "normal range?"
  • What follow-up is needed?

Step 5: Bring the groups back together. Ask each recorder to display the health record on the overhead projector and explain the group's analysis of the record and approach to follow-up. Encourage participants from the large group to add their comments.

Step 6: After all of the parts of the health record have been discussed, ask participants:

  • When you were analyzing your part of the health record, was there other information that would have been helpful to know?
  • What are some important relationships between the different screenings and exams?
  • Now that you've reviewed the complete health record for this child...
    • what would you tell the parents about:
      • the child's strengths in the areas of health and development?
      • the health concerns and the follow-up needed?
    • what staff and health professionals should be involved?
    • what would you want the classroom teachers to know?
    • how would you document the process?

Points to Consider:

  • Screening and exam results that are "outside the normal range," "abnormal," or "failed" mean that the child might have a health problem. Such results must be followed up by rescreening and further evaluation by the health care provider to determine if the child has a health problem and, if so, what treatment is necessary.
  • Each child's complete health record should be assessed, since many health problems and screening and exam results are interrelated. For example, if a child is diagnosed with dental problems such as Baby Bottle Tooth Decay, it is important to identify possible causes in nutrition (e.g., use of bottle, sweets) and possible effects on growth (e.g., failure to thrive or overweight).
  • The results of screenings, exams, assessments, diagnoses, and treatment recommendations must be explained to parents and key staff who care for the child. This should be done:
    • by a well-informed person;
    • in clear terms and language that the parent(s) understand; and
    • with sensitivity to the concerns of the parents and staff.
  • Careful documentation is crucial for a comprehensive review and appropriate assessment, treatment, and follow-up to meet each child's health needs.

"Reviewing Health Records [A Learning Activity]." Well-Child Health Care: Making It Happen. Training Guides for the Head Start Learning Community. HHS/ACF/ACYF/HSB. 1998. English.

Last Reviewed: November 2009

Last Updated: August 31, 2015