Occupational Health Records/Documentation- Done Flashcards
Tips for safe computerized records
- Protocols for access
- Limited access
- Password protected
Health records
The records for which the OHN must assume professional and legal accountability
Employees have right to privacy in the following areas
- Detailed physical findings
- Diagnoses
- Non work related health information
When should recordkeeping policies be communicated to employees
- At time of hire
- Annually
- As needed
Without signed consent of the worker ————– cannot be released
Specific content, other than assessment about the persons ability to work
Health records must be stored in ——– that only health care professionals have access
A locked file
Information can be released for the following reasons
- Required by law
2. With proper consent
Examples of when release of information would be required by law
- For governmental agencies
- OSHA
- Public health dept
- Designated representatives
Examples of types of consent
- Subpoena
- HIV
- 1910.1020
Informed written consent for release of information should include the following information
- Identify client
- DOB
- Reason for consent
- Specific type of information and how much information to be released
- Name of person who should receive disclosure
- Purpose of disclosure
- Period of time
- Effective date
- Witnesses
- Signatures
- Date consent signed
Special cases in release of information
- Suicide threats
- Reportable diseases
- Elder/spousal/child abuse
- Firearm injury
Documentation guidelines
- Accurately, factually an completely
- Paper files- do not leave blank spaces
- Keep current on all recordkeeping/privacy issues
- Document any employee instruction
- Use appropriate forms
- Organize and separate records
- Store records as required by regulations/legislation
Laws to review for health records/ documentation
- OSHA 29 CFR 1910.1020 Access to Employee Exposure and Medical Records
- Blood borne Pathogens 29 CFR 1910.1030
- Americans with Disabilities Act 1990 (42 U.S.C. 12101 et seq.)
- Family Medical Leave Act 1993
- Federal & State Privacy Rights and Laws, HIPPA Regulations
Ten guidelines for workplace privacy policy
- Identify group/individual to manage privacy issues
- Conduct privacy audit to determine areas of risk
- Develop comprehensive plan addressing employee monitoring and protection of sensitive information. Distribute policy
- Present policy as tool to balance between employee’s right to privacy and employers duty to provide safe workplace
- Train managers and employees on policy
- Train managers and employees on appropriate use of electronic communication
- Determine extent of current monitoring and surveillance and limit activities to work and safety related items
- Limit disclosure of surveillance information
- Establish procedure for responding to third party requests
- Develop internal systems and procedures
Daily log
Tally of all patients/clients seen in one day in health unit regardless of the reason for the visit
Employee health records
- confidential
- cumulative accounts for each worker
- one of the most important records in the health unit
- should be pulled or accessed on computer during each visit
Examples if contents of employee health record
- Routine health evaluations
- Treatment of illnesses/injuries
- Health protection efforts
- Health promotion efforts
- Health education efforts
- Disease prevention efforts
Monthly and annual reports
Document incidence of illness and injury in various departments as well as morbidity and absenteeism