School Notes in America: What Happens to Children’s Sick Days When the Bell Rings

Research

As American schools fight historic absenteeism, we at DrHouse analyzed 5,780 pediatric telehealth visits to measure a part of childhood illness that attendance data rarely captures: the paperwork of a sick day.

The share of visits ending with a doctor’s note rises and falls with the school calendar, climbs with each stage of school, and reaches one in two for visits booked on weekday mornings during the school year.

Key findings

• In summer, 11.3% of children’s telehealth visits end with a doctor’s note. During the school year it’s 35.9%, a 3.2x jump (p < 0.001).
• The climb follows the school calendar: 4.1% in July, 23.5% in August, 35.6% in September.
• December is the busiest month for children’s visits, yet the note rate falls to 23.2% as winter break arrives, the lowest of any school month.
• The rate rises with each stage of school: 8.4% for ages 0-4, 30.9% in elementary, 37.8% in middle school, 41.9% in high school.
• A high schooler’s visit is twice as likely to end with a note as the average adult’s: 41.9% vs. 20.8%.
• February is the peak. Nearly half of children’s visits that month (46.5%) end with a note.
• During school months, half of children’s visits booked on weekday mornings between 6 and 10 a.m. end with a note (49.9%). On weekend mornings it’s 12.2% (p < 0.001).
• Rates run from 47.4% in New Jersey to 22.8% in Virginia across the 16 states with enough visits to report.

All figures cover completed DrHouse telehealth visits by patients under 18. They show whether the treating physician issued a note, not why one was requested or whether a school required it. Cite freely, with attribution to DrHouse, “School Notes in America,” 2026.

Prefer the designed report? Download the PDF version of this case study here!

The hidden paperwork of a sick day

A child wakes up with a fever on a Tuesday morning. A parent has to decide fast. Can their child go to school, and can they still go to work? Do they need to see a doctor? What documentation does the school require? And if a doctor’s note is needed, how do they get one while caring for a sick child and still working?

In July, most of those questions never come up. A sick child is just a sick child, and only 4.1% of children’s visits end with a doctor’s note. By September, more than one in three do. The data doesn’t record what each note is for, but the timing points to the school office.

Attendance is under more scrutiny than it was before the pandemic. Chronic absenteeism means missing 10% or more of the school year, excused or not. It nearly doubled after COVID, from about 15% of U.S. public school students to a peak of about 28%, and was still around 24% in 2023-24, by AEI’s Return to Learn tracker.

Plenty of public data tracks how often children miss school. Much less exists on what families have to do when a child misses it.

This study offers one window into that paperwork. We analyzed 5,780 completed DrHouse telehealth visits by patients under 18, between February 29, 2024 and August 17, 2026, and checked whether each one ended with a doctor’s note issued by the treating physician. It’s a study of documentation, not attendance records, and it reflects DrHouse users, not all pediatric care.

The twelve-month shape of a school note

Here is the full year, month by month. The school calendar is legible in every row.

Month	Note rate	School status
July	4.1%	Out
August	23.5%	Partly in session
September	35.6%	In
October	35.7%	In
November	35.5%	In
December	23.2%	Winter break
January	39.6%	In
February	46.5%	In · historic flu peak
March	36.3%	In
April	37.8%	In
May	33.8%	In
June	9.5%	Mostly out

During the school year (September to May), 35.9% of children’s visits end with a note. Over summer break (June to August), it’s 11.3%. That’s a 3.2x difference (p < 0.001). The school-year rate also held steady across both complete academic years in the data: 36.6% in 2024-25 and 35.8% in 2025-26.

September through November sits on a plateau in the mid-30s. Then the line drops in December and peaks in February at 46.5%, when a full school calendar overlaps the month that most often brings the peak of U.S. flu activity.

Between July and September, the share of children’s DrHouse telehealth visits ending in a doctor’s note climbs nearly ninefold, from 4.1% to 35.6%.

Is it the germs or the bell?

The obvious objection: children do get sicker when school starts. Isn’t this just the back-to-school plague showing up in the data?

Partly, maybe. But this study measures a share of visits, not a count of sick children. More sick kids means more visits. The share only climbs if each visit becomes more likely to end with a note. Four things in the data suggest illness isn’t the whole story.

• August. It has fewer than half as many children’s visits as December, yet the note rate jumps more than fivefold from July, to 23.5%. August is a split month for American schools. Much of the South and Sun Belt opens in early to mid August, while much of the Northeast waits until late August or after Labor Day.
• December. No month brings more children’s visits, yet the note rate drops to 23.2%, the lowest of any school-year month. The likeliest reason is winter break.
• The toddlers. Children aged 0-4 catch everything, but they are below school age. Their note rate is 8.4%, the lowest of the four child age groups. If sickness alone drove documentation, the daycare set would top the chart.
• The adults. They go through the same winter respiratory season, and most have no school calendar to answer to. Their monthly rates run from 18.9% to 23.2%, a spread of about four points. Children’s run from 4.1% to 46.5%.

Illness clearly plays a part, and an observational dataset can’t fully separate the two. September’s 35.6% arrives before respiratory season peaks. February’s 46.5% looks like school plus flu, stacked. The bell appears to set the baseline. The germs appear to raise the ceiling.

The grade ladder

The school-year effect isn’t uniform across childhood. It climbs a staircase, one step per stage of schooling.

Age group	School stage	Note rate	vs. average adult (20.8%)
0-4	Pre-K / daycare	8.4%	0.4x
5-11	Elementary school	30.9%	1.5x
12-14	Middle school	37.8%	1.8x
15-17	High school	41.9%	2.0x

These are age bands, not the same children followed over time. The biggest step sits at the school door: 8.4% below school age, 30.9% in elementary school, nearly four times as high.

From there the rate keeps climbing. The data can’t say exactly why, but the pattern aligns with the growing role attendance plays as students get older. In middle and high school, absences can start to affect make-up work, tests, course credit, graduation requirements and athletic eligibility. In a nationally representative University of Michigan Mott Poll, nearly two-thirds of parents of 11 to 18 year olds said their child worries about how sick days may affect their grades.

A high schooler’s DrHouse telehealth visit is twice as likely as the average adult’s to end with a doctor’s note: 41.9% vs. 20.8%.

The school-morning scramble

For parents and students, a sick day is a health decision and an administrative one. It shows in the booking times: the moment a parent reached for the phone, not the appointment slot, converted to each state’s local time.

During the school months, children’s visits booked on weekday mornings between 6 and 10 a.m. end with a doctor’s note 49.9% of the time. In the same window on weekends, it’s 12.2%. A fourfold gap (p < 0.001). And on the same weekday mornings in summer, with school out, the rate falls to 15.7%.

Same weekdays. Same hours. No bell.

During the school year, half of children’s DrHouse visits booked on weekday mornings between 6 and 10 a.m. end with a doctor’s note. On weekend mornings, about one in eight.

Anyone who has gotten a child ready for school can picture the morning behind those numbers. A child wakes up sick. A parent tries to figure out next steps, often before their own workday has begun.

“Missing school is an important issue to address, and these findings clearly show that the demand for doctor’s notes increases when children are in school,” said Dr. Robert Chandler, a physician with DrHouse.

“While documentation policies serve an important purpose, requiring families to visit an urgent care center or primary care office for a minor or improving illness can create real challenges. Appointments may not be immediately available, and parents may have to miss work and encounter financial strain simply to obtain a note. Telehealth offers families a faster, more accessible way to have their child evaluated and, when medically appropriate, receive the documentation they need without leaving home.”

The state map: same country, very different paperwork

Where families live makes a difference, too. Among the 16 states with at least 100 children’s visits in the dataset, the share ending in a note more than doubles from bottom to top.

State	Share of children’s visits ending in a note
New Jersey	47.4%
Pennsylvania	43.9%
South Carolina	41.1%
Texas	39.2%
Tennessee	35.8%
Indiana	30.4%
Ohio	29.3%
Michigan	28.1%
Florida	27.4%
Illinois	27.2%
California	26.9%
North Carolina	25.6%
New York	25.5%
Arizona	24.4%
Georgia	24.4%
Virginia	22.8%

In New Jersey, a child’s telehealth visit ends with a note nearly half the time. In Virginia, fewer than a quarter do. The differences across the 16 states are jointly significant (p < 0.001).

These numbers should not be read as a ranking of states or school systems. They are descriptive and unadjusted: attendance policies vary by state and district, and so do age mix, insurance mix and local telehealth habits. Most of these states also have fewer than 300 children’s visits in the data, so small gaps between neighbors mean little. What the spread does show is that families’ experiences with medical documentation are far from uniform.

The insurance gap

There’s also an access question. Among children’s visits with an insurance carrier on file, 31.7% end with a note. Among visits with no carrier on file, 26.3% do, a 5.4-point gap (p = 0.001).

That doesn’t establish that insurance coverage caused the difference. Insured and uninsured families can differ in many other ways. But it highlights something worth weighing whenever medical documentation becomes part of school attendance: requiring proof from a healthcare professional can create an extra hurdle for families who have more difficulty accessing care.

What a school note actually is, and when schools ask for one

A school absence note is a short written confirmation from a licensed clinician that a child was evaluated and that an absence, a return to class or a break from PE is clinically supported. For this analysis, a doctor’s note means documentation issued by the treating physician following a telehealth visit. At DrHouse, physicians issue notes at their clinical discretion, following an evaluation and when medically appropriate.

When schools ask for one is decided district by district, and the range is wide. Some require no medical documentation for routine absences. Depending on the school, documentation may be relevant for:

• Extended or consecutive absences
• Determining whether an absence is excused
• Making up missed tests or assignments
• Returning to school after certain contagious illnesses
• Medical accommodations or excusal from physical education
• Meeting graduation or grade promotion requirements

A note doesn’t necessarily remove an absence from chronic-absenteeism counts, which generally include excused and unexcused absences alike. It may instead affect how a school or district handles the absence.

Whether schools should ask at all is a live argument. The American Academy of Pediatrics treats school attendance as a health issue: chronically absent students face worse academic and health outcomes. The CDC’s 2024 school infection-prevention guidance urges schools to carefully consider any requirement for a provider’s note for illness-related absences, because visits made solely to obtain one can burden families and the healthcare system.

This study doesn’t take a side in that debate. It measures documentation, not the rules behind it.

What this data can and can’t say

• It’s one telehealth platform. Families may be especially likely to use telehealth when documentation is needed, so note rates on DrHouse may run higher than in traditional pediatric settings. The figures are not nationally representative of all pediatric healthcare.
• It counts notes, not their purpose. The tight fit with the academic calendar is consistent with school and daycare requirements playing a large part, but the data can’t confirm it. Some notes serve other ends: sports clearance, camp forms, a parent’s employer.
• It’s observational and visit-level. It cannot establish that school policies caused the differences. Seasonal illness patterns, patient mix and reasons for seeking care may all contribute, and repeat visits by the same patient are not linked..

Quick answers

How often do children’s telehealth visits end with a doctor’s note?

On DrHouse, 35.9% of the time during the school year and 11.3% over summer break.

Do schools require a doctor’s note for an absence?

It varies by district. Short absences often need only a parent’s word. A note may be requested after several consecutive missed days, for excused-absence coding, test make-ups, return after certain contagious illnesses, or PE excusal. Check the parent handbook.

In which month are children’s visits most likely to end with a doctor’s note?

February. On DrHouse, 46.5% of children’s visits that month end with a note.

Which age group’s visits most often end with a doctor’s note?

Among children, high schoolers. On DrHouse, 41.9% of visits by patients aged 15-17 end with a note, about double the adult average (20.8%).

Can a child get a doctor’s note for school through telehealth?

Often, yes. At DrHouse, physicians issue doctor’s notes at their clinical discretion, following an evaluation and when medically appropriate. A note is not guaranteed, and each school decides what documentation it accepts.

Why this matters

This dataset doesn’t measure how sick American children are. It measures something less visible: how often a medical visit also becomes a documentation event. And that administrative layer follows the school calendar closely.

For schools, medical documentation can help manage attendance. For healthcare professionals, unnecessary documentation requirements can add administrative work to routine childhood illness. For parents, it’s simpler: My child is sick. What do I need to do before school starts?

“This research shows how quickly a routine childhood illness can become a healthcare, school and workplace challenge for an entire family,” said Ergo Sooru, CEO of DrHouse. 

“Responsible attendance policies are important, but families also need practical ways to access appropriate care and documentation. By connecting parents and children with physicians from home, telehealth can help reduce unnecessary disruption while keeping the child’s health at the center of every decision.”

Telehealth can’t eliminate the complexity of school attendance policies. But when a child needs medical attention, it can give families another way to reach a licensed healthcare professional without adding a waiting-room trip to an already difficult morning.

The findings raise a broader question for schools, healthcare providers and employers: how can systems support responsible school attendance without making a child’s routine illness unnecessarily disruptive for an entire family?

Methodology

Findings are based on 5,780 completed telehealth visits by patients under 18 on the DrHouse platform between February 29, 2024 and August 17, 2026, drawn from a full dataset of 93,633 completed visits (pediatric visits make up 6.2%). The adult comparison group is the 87,811 completed visits by patients 18 and over, and the 20.8% adult figure is a year-round average. Forty-two records with implausible birth dates were excluded from age-based analyses.

A visit counts as ending in a doctor’s note when documentation was issued by the treating physician. Notes are issued at the physician’s discretion, when medically appropriate. The dataset records that a note was issued, not its purpose, so some pediatric notes may relate to purposes other than school attendance. The figures should be read as a measure of documentation demand on a telehealth platform. They are observational, reflect DrHouse users and are not nationally representative of all pediatric healthcare.

“School year” means September to May and “summer break” means June to August. Because some U.S. districts return during August, this produces a conservative estimate of the difference. Counting August as school time widens the ratio to roughly 5.3x (35.1% vs. 6.7% in June and July). Restricting to a balanced two-year window (July 1, 2024 to June 30, 2026) gives 35.9% vs. 13.1% (2.7x, p < 0.001). Monthly figures pool all occurrences of each calendar month.

Age bands follow common U.S. school stages (0-4 pre-K and daycare, 5-11 elementary, 12-14 middle school, 15-17 high school) and compare different patients, not the same children over time. Analyses are visit-level. The dataset did not contain patient or physician identifiers that would allow linking repeat visits. “Insured” means an insurance carrier was on file for the visit.

Booking-time figures use the timestamp at which a visit was scheduled, not the appointment time, converted from UTC to the primary time zone of the patient’s state (an approximation for states spanning multiple zones).

State figures are reported only for the 16 states with at least 100 under-18 visits. They are descriptive and unadjusted for age, insurance, month or patient mix.

Statistical tests, all two-sided:

• School year vs. summer: p < 0.001 (chi-square)
• Weekday vs. weekend mornings, school months: p < 0.001 (two-proportion test)
• Across the 16 reportable states: p < 0.001 (omnibus chi-square)
• New Jersey vs. Virginia, the observed extremes, exploratory: p < 0.001 (two-proportion test)
• Insured vs. uninsured: p = 0.001 (two-proportion test)

All reported data are aggregated and de-identified. No personally identifiable patient information is published.

Sources

• U.S. Department of Education, Chronic Absenteeism
• American Enterprise Institute, Return to Learn Tracker
• Centers for Disease Control and Prevention, Flu Season
• Pew Research Center, back-to-school dates by region (2023)
• University of Michigan C.S. Mott Children’s Hospital National Poll on Children’s Health, Too sick for school? (2024)
• American Academy of Pediatrics, The Link Between School Attendance and Good Health (2019)
• Centers for Disease Control and Prevention, When Students or Staff Are Sick (2024)
• DrHouse, School Notes in America: What 5,780 Pediatric Telehealth Visits Tell Us About the Hidden Paperwork of a Sick Day, case study (PDF) (2026)