Child Care Basics: Documentation, Policies, and Ethical Care Practices

Why Documentation Matters

Documentation is the written record of what happened, what was observed, and what actions were taken. In child care, it is not “extra paperwork”—it is a safety tool, a continuity-of-care tool, and an accountability tool.

1) Safety

• Tracks risks and responses: allergies, injuries, medication doses, toileting concerns, and unusual symptoms.
• Supports timely decisions: clear notes help you notice patterns (e.g., rash after a certain snack) and respond appropriately.
• Creates a reliable timeline: if an incident occurs, accurate times and actions reduce confusion and help ensure appropriate follow-up.

2) Continuity of Care

• Helps the next caregiver: shift changes, substitutes, and shared care settings rely on consistent records.
• Prevents missed steps: medication schedules, allergy plans, toileting supports, and authorized pickup lists must be easy to verify.

3) Accountability and Professionalism

• Shows what you did and why: especially important for incidents, health concerns, and policy-related decisions.
• Protects children and caregivers: objective records reduce misunderstandings and provide clarity if questions arise later.

Objective vs. Subjective Writing (and Why It Matters)

Objective writing records observable facts: what you saw, heard, measured, or did. Subjective writing includes opinions, assumptions, labels, or interpretations that cannot be verified.

What to Record (Objective)

• Who: child’s name (and relevant staff involved).
• What: observable behavior, symptoms, injury description, exact words spoken (when relevant).
• When: date and time (start/end if needed).
• Where: location (playground, nap area, bathroom).
• Action taken: first aid provided, parent/guardian notified, medication administered, policy steps followed.
• Outcome: child’s response, condition after action, any follow-up needed.

What to Avoid (Subjective)

• Labels: “bad,” “lazy,” “attention-seeking,” “dramatic.”
• Assumptions about intent: “He did it on purpose,” “She was trying to get her way.”
• Diagnoses: “has an ear infection,” “is autistic,” unless confirmed and documented by appropriate sources and relevant to care.
• Blame: “Parent didn’t care,” “Other child attacked.”
• Unnecessary personal details: family issues not directly relevant to care and not authorized to record.

Objective vs. Subjective Examples

Step-by-Step: How to Write a Strong Child Care Note

Step 1: Start with the purpose

Choose the correct form (daily log, incident report, medication log, toileting record, allergy exposure record). Write only what belongs in that record.

Step 2: Capture the facts in real time

• Write notes as soon as it is safe and practical.
• Use exact times (not “earlier” or “later”).
• Use measurable descriptions: size, location, duration, frequency.

Step 3: Use neutral, specific language

• Describe what you observed: “cried,” “ran,” “said,” “hit,” “coughed,” “ate,” “slept.”
• Quote exact words when relevant: Child said, “My tummy hurts.”
• Avoid emotional or moral judgments.

Step 4: Document actions taken and notifications

• What you did (first aid, separation, comfort, policy step).
• Who you notified and when (guardian, supervisor, health lead).
• Any instructions received (e.g., guardian requested monitoring).

Step 5: Close with outcome and follow-up

• Child’s condition after action.
• What to watch for.
• Any required next steps (form signature, supply replacement, plan update).

Common Policy Areas You Must Know (and Document Correctly)

Policies vary by setting, but these areas are common. The key is to follow the written policy and document the steps you took.

Authorization for Pickup

Goal: ensure children are released only to approved individuals.

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• Maintain an up-to-date authorized pickup list with names, relationship, and verification method.
• Verify identity when the person is unfamiliar or when policy requires it (e.g., photo ID check).
• Document exceptions (e.g., emergency authorization) exactly as policy allows.

What to document: pickup time, name of person, ID check (if done), any unusual circumstances, and who approved any exception.

Medication Handling

Goal: prevent dosing errors and ensure medication is given only with proper authorization.

• Accept medication only per policy (original container, labeled, within date, required forms completed).
• Follow the “right” checks (right child, medication, dose, time, route; plus right documentation).
• Store securely as required (locked, temperature-controlled if needed).
• Never document before administering; document immediately after.

What to document: date/time, medication name, dose, route, reason (if required), who administered, witness (if required), and any observed effects or refusal.

Allergy Plans

Goal: prevent exposure and respond quickly if exposure occurs.

• Know each child’s allergy plan (triggers, symptoms, actions, emergency medication authorization if applicable).
• Prevent exposure by checking ingredients, avoiding cross-contact, and following meal/snack procedures.
• Document any suspected exposure and the response steps taken.

What to document: what food/item was involved, how exposure may have occurred, symptoms observed (with times), actions taken, and notifications.

Toileting Support

Goal: provide hygienic, respectful support and track patterns that affect care.

• Record toileting events as required (diaper changes, toilet attempts, accidents).
• Use respectful language and avoid shaming terms.
• Note concerns that may require follow-up (blood in stool, diarrhea frequency, pain statements).

What to document: time, wet/soiled, stool description if relevant (e.g., “loose,” “hard”), skin condition (e.g., “redness noted”), supplies used (cream only if authorized), and any child statements like “It hurts.”

Photos, Privacy, and Media Use

Goal: protect children’s privacy and follow consent rules.

• Use photos only with documented permission and only for approved purposes.
• Avoid identifying details when policy requires (name tags, addresses, documents in background).
• Never use personal devices if policy prohibits it.

What to document: consent status, where images are stored, and any incident of accidental capture/sharing and corrective steps (per policy).

Confidentiality

Goal: share information only with those who need it to provide care and only through approved channels.

• Keep records secure (locked storage, password-protected systems).
• Discuss children only in private and only with authorized staff/guardians.
• Use minimum necessary details in shared spaces (whiteboards, group messages).

What to document: only what is relevant to care and required by policy; avoid recording gossip, speculation, or unrelated family information.

Mini Practice: Rewrite Vague Notes into Objective Statements

Rewrite each note so it includes observable facts, times (when possible), and actions taken—without labels or assumptions.

Practice Set

1. Vague: “Jaden was out of control at circle time.”

   Objective rewrite (example): “At 9:10 a.m. during circle time, Jaden stood up, walked to the shelf, and knocked over a basket of books. When prompted to return to the rug, he said ‘No’ and lay on the floor. Staff moved the basket out of the walkway and guided Jaden to a seat; he sat for the last 3 minutes of circle.”

2. Vague: “Sofia had a bad day and was mean to others.”

   Objective rewrite (example): “Between 2:00–2:20 p.m. in the block area, Sofia grabbed blocks from two peers. When a peer reached for a block, Sofia pushed the peer’s hand away once. Staff intervened, separated materials, and prompted Sofia to hand back 2 blocks. No injury observed.”

3. Vague: “Eli is probably sick.”

   Objective rewrite (example): “At 11:35 a.m., Eli coughed repeatedly for about 1 minute and said, ‘My throat hurts.’ Temperature taken at 11:40 a.m.: 99.1°F (temporal). Eli drank water and rested on a mat for 10 minutes. Guardian notified at 12:05 p.m.”

4. Vague: “Parent was rude about the scratch.”

   Objective rewrite (example): “At 5:18 p.m. during pickup, guardian asked how the scratch occurred and stated, ‘This shouldn’t happen.’ Staff reviewed the incident note and showed the scratch location. Guardian signed the incident form at 5:22 p.m.”

5. Vague: “Nora wouldn’t use the toilet and had an accident.”

   Objective rewrite (example): “At 10:00 a.m., Nora sat on the toilet for 20 seconds and stood up without urinating. At 10:18 a.m., Nora’s pants were wet. Staff changed clothing and recorded a wet accident. Nora washed hands with assistance.”

Documentation Checklist (Use Before You Submit)

• Correct form: daily log vs incident vs medication vs toileting vs allergy record.
• Complete identifiers: child name, date, location, staff initials/signature as required.
• Clear timeline: exact times and sequence of events.
• Objective language: observable facts; quotes used when helpful; no labels/assumptions.
• Injury/health details: body location, size/color, symptoms, duration, temperature if taken.
• Actions taken: first aid, comfort measures, separation, cleaning, policy steps.
• Notifications: who was contacted, when, and how (in person/phone/message per policy).
• Follow-up: what to monitor, supplies needed, plan updates, required signatures.
• Confidentiality check: only necessary details; stored/shared through approved channels.
• Legibility and accuracy: no blanks; corrections made per policy (no erasing if paper-based).

Quick Reference: Ethical Decision-Making in Everyday Scenarios

Use this quick guide when you are unsure what to do. It is designed for everyday choices where policy, privacy, and fairness matter.

The “PAUSE” Quick Check

• P — Policy: What does the written policy require (pickup, meds, photos, confidentiality)?
• A — Authority: Do I have the authorization/training to do this, or do I need a supervisor/guardian?
• U — Urgency and safety: Is anyone at immediate risk? If yes, prioritize safety and then document.
• S — Smallest necessary disclosure: Who truly needs to know, and what is the minimum needed?
• E — Evidence: What did I actually observe, and what do I need to record objectively?

Everyday Scenarios and Ethical Responses