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Doctors Notes: Return to Daycare

Doctors Notes: Return to Daycare
 

We had a discussion on Daycare.com brought up by forum member “daycare” that got me to thinking about the policies in my child care regarding ill children returning to care.

Ugh vent… Kid has Croup
“So the DCM that said kid has a fever from teething turned out that the DCP took her to the DOC today and the kid has croup. They said that the doctor said it would be ok for the kid to come back to DC tomorrow?”

Many providers rely on Doctors notes to be the final decision of whether or not the child can return to care. I see the Doctors notes as a piece of the decision I need to make but I don’t go solely on it to allow re-admittance.

I’ve had some situations with former clients who put me to the test with Doctors notes. I learned the VERY hard way to not go against my policies even with a note stating the child can return to care.

When I exclude a child because of illness I usually just give a time frame for when they can return symptom free. In some extreme cases I require the child to be assessed by a Doctor before readmitting into care. Sometimes parents decide to take the child in and obtain a note to admit the child back into care because they feel the time exclusion is not warranted.

For my business, the best practice is to require the note to contain only three things:
Diagnosis
Is the child contagious?
Treatment plan

I do not ask for the Doctor’s opinion on whether the child can safely return to care. I make the decision myself on a case by case basis.

My reasoning for not accepting “return to child care” notes is that I know the Doctor can’t possibly know the population of children the child is returning to. There is often a common belief that the other children in care have already been exposed to the communicable illness and most likely their patient actually got the illness in day care.

The physician can not know whether or not we have newborns, special needs children, immunocompromised children, or brand new kids starting the childcare who haven’t even met their patient. They don’t know if we have children who have been out on a vacation. They also may not be aware that every other child in the daycare has been well with perfect attendance meaning there is a high likelihood their patient is the first and only currently ill child.

When Doctors are assessing an acutely ill child they have the parental history of the illness, the child’s medical history, and how the child presents to them at the moment. They may not be aware that the child has been given fever reducing medicines that can mask fever which is often the number one reliable index for communicability.

In these tough economic times there is a lot of pressure on Doctors to please their customers. If they have a parent telling them that they are there because the child was excluded from child care they may feel obligated to help their customer. If there is no real (fever) indication that the child is most likely contagious they may feel more confident that the illness does not warrant an exclusion.

If they believe the other children have already been exposed and most likely passed the illness to their patient they may feel it is okay for their patient to be with the already exposed kids. They can’t possibly know our population so this can be a critical error in thinking that brings illness back into your child care the next day.

I am the one responsible for deciding the risk of the child returning. I have to protect myself, my helper, my child, and the other daycare kids. I know all of their medical conditions and their attendance. I also know what we are capable of doing incorporating a mildly ill child into our routine. I know how much adult time we can divest to the ill child and whether or not it is feasible to provide care separately to protect those who are well and haven’t been exposed.

I have had too many experiences where children have been diagnosed with asthma, allergies, teething, and “it’s no big deal because the kids are already exposed” viruses and returned to childcare with Doctors notes and then ended up with some pretty nasty illnesses in the house.

I’ve had a child return after a two week break where she got Hand Foot and Mouth disease and five days later half my kids had it. The child’s doctor believed it was okay to return his client not knowing that the children hadn’t even seen each other the two weeks previous. That single error resulted in a lot of missed work for a number of my families.

I’ve also had situations where a child I excluded came back the same day with a return note stating a “cold” diagnosis and an order to frequently wash our hands. I accepted the note and believed my concern was overcautious  and allowed the child back in for the afternoon. Twelve hours later the child was clinging for life in a pediatric intensive care unit with a highly contagious form of bronchiolitis. Now I try to use the Doctors notes as a piece of information in my decision whether or not to return a child to care. I don’t allow it to be the final decision. If I don’t agree with the Doctor I will often call and get and give more specific information from them. It is important to have a signed medical consent allowing the provider to talk directly to the Doctor should  there be a return note that goes against your policies.  When you can share with them your history of the illness and your current children’s health status and attendance they often reconsider the return and assist you with working with the parent to understand why the return note won’t be acceptable at this time.

We are the gatekeeper of illnesses into our home. It’s not a perfect science and we all make mistakes in judgment.  It’s important to look at the whole picture of return notes and make a plan for how you will handle these notes. Sometimes it means going through the conflict with the parent and working with the Doctor directly to make a sound decision that is best for you and your group.

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