CHAPTER 15: Records

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:

  1. documentation of employee hazard exposures

  2. application of employee health data to job placement

  3. documentation of employee health over time

  4. provision of data for use in health program evaluation

  5. fulfillment of regulatory requirements

Personal Health Records

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:

  1. Results of physical examinations

  2. X-ray and laboratory reports (including EKG, pulmonary function results, audiograms)

  3. Acute care entries and progress notes (an additional separate Acute Care Register is often also kept)

  4. Record of immunizations

  5. Occupational and Medical history

  6. Hazard exposure record

  7. Health programs participation record

  8. Informed consent forms and authorizations for release of information

  9. Documentation of refusals to undergo examination, testing and program participation

  10. . Workers' compensation and insurance medical records

  11. Progress notes for rehabilitation

  12. Consultant reports.

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.

Environmental Hazard Records

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.

Miscellaneous Records

In addition to administrative records common to all organizations, the occupational health service keeps certain additional records which have unique purposes.

These include:

  1. Daily log of the number of workers seen and services performed. This record is useful for assessment of the impact of workplace health hazards on the workforce and is also a source of data to measure the effectiveness of existing hazard controls and injury or illness preventive measures.

  2. Health program records and reports. These usually contain data useful in the evaluation of specific designated ongoing programs such as hearing conservation, environmental monitoring, and employee assistance.

  3. Drug register. This is a mandatory record of medications held and dispensed to workers by the service.

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.

Keeping the Records

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:

  1. Is this information required by regulation?

  2. Will this information be used?

  3. Will its use justify the cost of maintaining it?

  4. Can the information be obtained easily and with accuracy?

  5. Will the process of obtaining the information contravene or compromise legislated human rights?

  6. Are secure facilities available to store the record for the required retention period?

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.

Format of Records

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.

PATIENT ENCOUNTER FORM (Form 15.1)


                                    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


INDIVIDUAL HISTORY FORM (Form 15.2)


 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


AUTHORIZATION TO RECEIVE OR RELEASE MEDICAL INFORMATION (Form 15.3)


 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)