No matter how small an occupational health service, record-keeping is a necessary part of its activities. In addition to keeping administrative and billing records, an occupational health service must maintain at least two other types of records. These are Personal Health Records and Environmental Health Records.
Records are never an end in themselves; they are tools that fill a need. In an occupational health service, the purposes to which records are put are:
This set of records concerns the health status of each individual worker. It inevitably contains personal, privileged information which has special significance in law. Chapter 30 describes the ethical constraints on physicians and nurses with regard to the release of personal information from these records outside of the facility and especially to the employer. These obligations also apply to the maintenance and internal use of company-initiated personal health records. The physical record is normally the property of the employer or, in the case of an occupational health service serving many employers, whoever caused the record to be created in the first place. The right of access to the information it contains is absolutely controlled by the individual worker, however. The information is held in trust by the physician or nurse who compiled it and the employer's access is limited to the physician's or nurse's interpretation of that information in the form of job-oriented statements of fitness to work. With certain exceptions under the law, only the worker himself or herself can authorize release of health information from his or her personal health record.
Personal health records should be kept in their original handwritten form even if typed or computerized versions also exist. For maximum accuracy and medico-legal reliability, entries should be made chronologically as the worker is seen, and each should be signed by the person making the entry. It is important that entries concisely but accurately and completely reflect the care given and actions taken on the employee's behalf.
A worker's personal health record should only reflect his/her health status insofar as it applies to the job. The content may therefore vary a great deal. The information which is usually found in the record includes:
Current records of first aid treatment are often kept at the first aid station at each worksite rather than at a central occupational health clinic in a plant, although old logs are usually stored there. This permits accidental injuries to be recorded at the worksites where they occur, thus eliminating the need for an employee with a trivial injury to leave work and go to the clinic simply to record the occurrence. The occupational health centre or clinic should keep a record of all first aid treatment which it has itself provided. This record is called the Acute Care Register.
First aid records are sometimes mandated by government regulation and are always important to the assessment of compensation claims. They are the responsibility of designated first aid or operations personnel. First aid records also provide data vital to the assessment of the company's accident prevention program.
Records a employee absenceand the regulation of absence from work are supervisory responsibilities. It is not the role of the occupational health service to police or enforce personnel regulations for the employer, but it may provide assistance by evaluating possible medical reasons for persistent absence and by participating in care provided to employees by other health agencies.
These records concern health aspects of the workplace rather than the individual employee, although documents on work procedures and protective clothing may apply to a particular employee or group of employees and may be incorporated in their personal health records as well. Basically, environmental hazard records describe conditions affecting worksite hygiene and safety.
Environmental hazard records include site visit reports, hazard monitoring results, worksite health and safety committee reports and accident investigation files. These records are normally produced and maintained by the employer's safety or hygiene staff, but in a small company they may be the responsibility of designated operations personnel. Personal health data should not be included in any of these records as they do not come under medical confidentiality guidelines. Access to them is therefore determined only by individual company policy and applicable legal requirements.
In addition to administrative records common to all organizations, the occupational health service keeps certain additional records which have unique purposes.
These include:
The occupational health service should also maintain a regularly updated record of hazardous materials used or produced at the worksite for the employers it regularly serves, if possible. If it is a plant or corporate occupational health facility this is essential. Maintaining a file of current Material Safety Data Sheets on these materials are a useful way of keeping this record, but these documents are notoriously shallow their information on long-term health effects and the information they provide on treatment. Reference works on the clinical toxicology of commercial materials are important to have on hand. Current copies of government occupational health and safety regulations and the company's own health and safety policies and procedures also should be readily available to staff.
The best way to keep records is the simplest manner consistent with convenient, economical and efficient but controlled access. Dedicated forms are particularly useful but a trial in use should always be carried out before they are introduced into full service. If coding systems are used they should be compatible with existing, widely recognized systems. For example, coding of illness and injury should be in accordance with either the International Classification of Diseases, Injuries and Causes of Death of the World Health Organization or Z16.2 of the American National Standards Initiative. This former is the standard system used by hospitals and in epidemiological research. This latter is a less complete system widely used for administrative purposes by workers' compensation board. Consistent coding enables the service to compare injury and illness data with results published from other sources.
Whichever filing system is chosen, records must be retained at least 30 years under the law, to permit access and review in the event subsequent health problems are identified. These records must be transfered to a responsible receipient or government agency if the employer or clinic goes out of business.
Computer storage permits automatic and very rapid retrieval of data in any combination and desired sequence. This is invaluable not only for worker health evaluation but for health program operations and audit. However, computers require special measures to insure secure control of access to recorded personal health information. Access to computerized records must be strictly controlled and policed.
When considering the possibility of recording specific information or ceasing to record it, the following questions should be asked:
In general, a good occupational health record would allow the reader to piece together a clear and coherent picture of the workers' exposure on the job, health status, treatments, job assignment, and identity and to do so at least 30 years after the fact. Many associations between chronic diseases and occupational exposures have been made using such records and they are always important legal documents.
The following forms are useful in occupational health practice. Form 15.1 is a Patient Encounter Form, providing details of the injury or illness and examination and can be used alone for routine acute care or fitness-to-work evaluations. This form can also be used in conjunction with Form 15.2 as a face sheet for registration and for the physician to fill out the chief complaint and physical findings. Form 15.2 is a more detailed Individual History Form designed for the patient to fill out while waiting to be seen. The form is designed to be used in conjunction with Form 15.1. This form captures information on the worker's employment history and occupational exposures, personal health, and health-related habits but is not overly long. It is not sufficiently detailed to replace a careful review of systems in a complex case or to guide counselling in a detailed health assessment but it is adequate for most general purposes and can save considerable time at the time the patient is interviewed. Form 15.3 is a release allowing medical records to be requested for consultation or medicolegal purposes. This form is a legal document complying with stringent California state laws governing confidentiality of medical records and is thus more elaborate than may be required in all jurisdictions. Even so, in the present climate of increasing litigation it is wise to be prudent in obtaining indisputable authorization for all transfers of confidential information. Form 15.4 is an optional form to document when a patient has been informed that some occupational health information may be shared. Some facilities and practioners prefer to give themselves this additional protection against later claims by workers that they did not understand that medical information might be shared in their cases.
These forms may be duplicated out of
this book on an individual basis but
authorization must be granted by the publisher
if they are to be reproduced in quantity or
for sale.
Name ________________________________
Med. Rec. No. ______________________
________________________________________________________________________
Employer _______________________________________________________________
Carrier ________________________ Social Security # ____________________
Home Address ___________________________________________________________
Home Telephone _______________________ Birthdate _______________________
Sex: M F Marital Status _______________________________
Reason for Visit: ( ) Accident Time In: ______:_____ a.m.
( ) Preplacement Time Out: _____:_____ p.m.
( ) Periodic Examination Date: _______________
( ) Other
History of Injury or Illness: _________________________________________
_______________________________________________________________________
Allergies: ____________________________________________________________
Temp: _____ Height: _____ Weight: _____ Pulse _____ BP ______ / _______
Abnormal Findings: ____________________________________________________
Head: ________________________________ Eyes: __ R ________ L _________
Ears: __ R ___________ L _____________ Nose: _________________________
Throat: ______________________________ Mouth: ________________________
Chest: _______________________________ Lungs: ________________________
Heart: _______________________________ Abdomen: ______________________
Inguinal Rings: ________ R ___________________ L ______________________
Spine: ________________________________ Extremities: __________________
Neurological Examination: _____________________________________________
Mental Status: ________________________________________________________
CbC: WBC ____ RBC ____ Hgb ____ Hct ____ MCV ____ MCH ____ MCHC _____
Serum chemistries: ____________________________________________________
Urinalysis: sp. grav _____ glu _____ alb _____ blood _____ micro _____
X-ray: ________________________________________________________________
Stool occult blood: ___________________________________________________
Fitness for Work: _____________________________________________________
_______________________________________________________________________
Recommendation for further examination or follow-up
_______________________________________________________________________
Name of Examining Sinature of Examining Date of Exam
Physician Physician
Name: _________________________________________________________________
Address: ______________________________________________________________
Telephone: Home __________________ Work ___________________
Date of Birth: ____________________ Sex: Male Female
Social Insurance No. ______________ Health Insurance No. _____________
OCCUPATIONAL PROFILE:
Fill in the table below listing all the jobs you have had (even
short-term, seasonal and part-time work).
Start with your present job first and go backward to the earliest
Use additional paper if necessary.
Brief Known
Work Type of Description Health
place/address From To Industry/Firm of Job Hazards
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Do you use any form of personal protection on the job?
Face Masks Gloves Ear plugs Steel-tipped shoes
SCUBA respirators Aprons Muff-type headsets Hard hats
Hoods/helmets Goggles Insulated clothing Other
Have you ever worked at any other dusty jobs: Yes No
If yes, please explain: ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you ever been exposed regularly
to any type of irritating gas? Yes No
Other chemical? Yes No Noise? Yes No
If yes, please explain: ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you ever been off work for a shift or longer
because of illness related to work? Yes No
If yes, please explain: ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
Have you ever to the best of your knowledge worked at a job handling
any of the following materials? Please circle if yes:
Asbestos Cotton Gasoline & Oil Silica (Sand & Quartz)
Asphalt & Tar Creosote Lead Powders (Please specify)
Benzene Dusts (specify) Mercury Solvents
Beryllium Dyes & Stains Paints Welding Fumes
Coal Fiberglass Pesticides/ X-Ray or Radioactive
Fungicides Materials
Plastics TDI or other
Isocyanates
Other: ______________________________________________________________
_______________________________________________________________________
Are you allergic to anything (substance you have encountered on the job,
foods, medicines, animals, pollen, etc.)? Yes No
If so, what are you allergic to? _____________________________________
What kind of a reaction do you get? ___________________________________
Do you smoke cigarettes? Yes Quit Never Smoked
If so, how many packs per day? ____ How long have you been smoking? ___
Do you use tobacco other than smoking cigarettes
(pipes, cigars, snuff dipper)? Yes No
If so how? ____________________________________________________________
How often do you use tobacco? ____ How long have you been using it? ___
Have you ever had a serious illness as an adult? Yes No
If so, write the year in which it occurred or started next to
the disease on this list. If the disease is not on this list,
please write it below.
Arthritis Glaucoma Malaria
Asthma Heart Disease Mononucleosis
Bronchitis Hepatitis Pneumonia
Cancer Hernia Prostate Trouble
Diabetes High Blood Pressure Rheumatic Fever
Emphysema Kidney Disease Tuberculosis
Epilepsy Liver Disease Venereal Disease
Other? ____________________________ When? ____________________________
Have you ever had surgery? Yes No
If so, please list operations and give approximate year. ______________
_______________________________________________________________________
_______________________________________________________________________
Are you taking any medicine now? Yes No
If so, please list them. (Include nonprescription drugs) ____________
_______________________________________________________________________
Have you ever had any of the following:
(Please circle the correct response)
Sudden or rapid weight loss without dieting? .................. Yes No
Loss of appetite? ............................................. Yes No
Unusual difficulty being comfortable during cold weather? ..... Yes No
Unusual difficulty being comfortable during hot weather? ...... Yes No
Overweight? ................................................... Yes No
A skin rash or sore which stayed for weeks? ................... Yes No
Sudden changes in your vision? ................................ Yes No
Double vision? ................................................ Yes No
Changes in your ability to hear? .............................. Yes No
Changes in your sense of smell? ............................... Yes No
Changes in your sense of balance? ............................. Yes No
Swelling in the armpit or groin? .............................. Yes No
Shortness of breath? .......................................... Yes No
Wheezing when you breathe? .................................... Yes No
A persistent cough? ........................................... Yes No
Coughing up blood? ............................................ Yes No
Pains or tightness in your chest? ............................. Yes No
Irregularity in your heartbeat or "palpitations"? ............. Yes No
Swelling in your ankles or legs? .............................. Yes No
Nausea or vomiting over several days? ......................... Yes No
Pain in your abdomen? ......................................... Yes No
Loose or running stools? ...................................... Yes No
Constipation? ................................................. Yes No
Vomiting blood? ............................................... Yes No
Black stools which looked like tar? ........................... Yes No
Blood in your stools? ......................................... Yes No
Yellow jaundice? .............................................. Yes No
Swelling or lumps in your breast (women) or testicles (men)? .. Yes No
Difficulty urinating or pain when urinating? .................. Yes No
Heavy or irregular menstrual flow (women)? .................... Yes No
Loss of consciousness for any reason? ......................... Yes No
Seizures or convulsions? ...................................... Yes No
Have you ever injured your back (enough to require a
visit to a physician or a chiropractor or medicine
stronger than aspirin)? ..................................... Yes No
Do you often have aching or pains in your neck, lower back
or in the back of your legs? ................................ Yes No
Do you have a "trick knee" or any other joint (elbow, ankle
or other) that tends to "give out"? ......................... Yes No
Have you ever had whiplash? ................................... Yes No
Did you play football in high school or college? .............. Yes No
Do you wear contact lenses on the job? ........................ Yes No
Do you often drive without seatbelts? ......................... Yes No
Have you ever felt, been told, or suspected that you had
difficulties dealing with alcohol ......................... Yes No
Have you ever used drugs for purposes other than as medication Yes No
I hereby authorize _____________________________________________________
________________________________________________________________________
(name and address of physician, hospital or health care provider)
to furnish to __________________________________________________________
________________________________________________________________________
(name and address of requester)
medical records and information pertaining to the medical history, mental
or physical condition, services rendered, or treatment given to:
_________________________________________________________________________
(PRINT - name of patient)
____________________________________________
(date of birth)
This authorization is limited to the following medical records and types
of information:
_________________________________________________________________________
The information supplied is to be used for the following purpose(s):
_________________________________________________________________________
This authorization shall become effective
immediately and shall remain in effect until: ______________________
(date).
I understand that the requester may not further use or disclose
the medical information unless another authorization is obtained
from me or unless such use or disclosure is specifically required
or permitted by law.
I further understand that I have a right to receive
a copy of this authorization upon my request.
Copy requested and received: Yes No Initials
Signed: ________________________________ Date: ______________________
Relation if not self: ___________________ Witness: ___________________
(Patient, Parent, (name and title)
Guardian or Legal
Representative
of Patient)