03.02.03 - Health Services Tracking Procedure & Documentation Process

Policy Number and Last Update (03.02.03/06-2019)

All IMSHS delegate agencies must track the provision of health care services and keep up-to-date health records (files) from all enrolled children by complying with the following procedures. The IMSHS Confidentiality Policy must be followed at all times during this process.

Tracking Procedures: The tracking system provides a quick way to see the present health status of any individual child in the program and to flag potential problems in managing the child's health care.

1. The delegate Health Services Coordinator (HSW) must record a child's health services on the Child Outcomes Planning & Administration: COPA.
   1. This tracking process begins from the time the child enters the program,
   2. is kept up-to-date daily, and
   3. is used to determine when the next services is due and what follow-up treatment is needed.
2. The HSW must:
   1. Record health services information received at the time of the child's enrollment and note when the next services are due;
   2. Record screening, examination, immunization, and treatment dates as services occur, and note outcomes as results are received; and
   3. Record follow-up services, dates, and transition information.

Health Services Documentation Process: Delegate agencies will keep health records per the IMSHS Filing Procedures and must specifically:

1. Inform parents of the health information to be collected, the uses of the information, and assure parents that use of information will be restricted to stated purposes. Explain the program's confidentiality policy and inform parents that they may review their child's records on-site upon request.
2. Obtain a signed consent for all services to be performed by the program and its contracted providers and a signed release of information form from parents before providing services and releasing any records or information to outside sources.
3. Maintain complete, accurate, and current medical, dental, and nutrition files for all children which include:
   1. Medical, dental, nutritional, and developmental histories;
   2. Parent consents and release of information forms;
   3. All screening results;
   4. Physical and dental examination forms (signed by the physician and dentist);
   5. Growth charts charted;
   6. Treatment/follow-up reports;Immunization status (updated after each given);
   7. Nutrition assessments;
   8. Medication forms;
   9. Copies of forms used to inform parents of screening/exam results and results of follow-up appointments;
   10. Written follow-up plans;
   11. Program Notes/Reports:
   12. Accident Report(s);
   13. Copy of child's Medicaid card or private insurance, if applicable.
   14. Noted sources of payment for health services; and
   15. Copies of other communication with parents.
4. Maintain health files cumulatively (i.e. a child's previous years' service records must be kept filed with the current year's records.) The previous years' progress notes, histories, exams, screenings, treatment, accident and medication forms should be attached to the back of the file with the year indicated. Expired consents, releases, and parent notification forms may be transferred to the prior year files.
5. Give parents records of all services provided to their child, including the physical form, dental form, nutrition assessment, immunization records, and required disabilities records. Have parents sign that they received the records and discuss with them the importance of these records and how to maintain them.

Monitoring, Reporting, and Analyzing Health Services Outcome Data:

1. Health services will be monitored per the IMSHS Monitoring procedure.
2. Data collected on the children's health services will be reported:
   1. Monthly to the Grantee Health Services Manager during site visits
   2. At the end of the season on the Office of Head Start Program Information report; and
   3. To the HSAC, Board, and Policy Committee per reporting requirements of each group.
3. The data will be analyzed by the Grantee HSM. The analyses will be discussed at the annual strategic planning meeting and used to plan for service delivery improvement.