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
Components of monthly and annual reports
- Picture of activities of health department and results achieved
- Concise/comprehensive summary
- Statistical and narrative form
- Comments on trends
- Makes recommendations to increase effectiveness of health program
- Call attention to significant health findings uncovered
- Should be used as an evaluation of OHN’s work
Narrative report translates significance of data listed
- How many man hours of work have been lost
- What are frequency and severity rates
- Are hazardous conditions being corrected
- Are safety rules being enforced
- Can illness and injury be reduced to a point that there can be a reduction in insurance premium
- Identify problem areas, health education, employee needs
- Statistical and narrative sections
- Cost benefit/cost effective analysis
- Picture of what goes on in relation to safety, welfare and health of all employees
- Material and statistical evaluation of health programs
- Provide management with information as to the workload and show where to plan special activities
Items to know when reviewing what are the premiums for your company
- SIC code/ NAICS code
- Workers compensation premium and top three highest cost medical conditions
- Group health insurance premium and top three highest cost medical conditions
Incidence rate
A standard measure of safety performance based on a formula
Formula for incidence rate
Number of new cases & accidents per year X *200,000 work hours per facility/ number of total hours worked at facility per year
How to calculate work hours per facility
Based on 50 week work year of 100 people working 40 hours per week
100x40x50=200,000 exposure hours per year
Storage and destruction of records
- should be kept as long as legally required
- cleared with management and legal counsel
- written into policy
- check local, state, federal regulations
Potential liability issues that can arise from documentation
- Invasion of privacy
- Defamation
- Libel
- Slander
Defamation
To harm another persons reputation by libel or slander
Libel
A defamatory written statement about a person that is false and published without just cause
Slander
A false and defamatory oral statement about a person
SOAP records
S=subjective
O=objective
A=assessment
P=plan
Subjective
Information obtained from the patient, symptoms reported by the patient/client, family, coworker, supervisor
Objective
Factual information resulting from nursing observations pertinent to the given problem; should reflect quantitative data when possible
Assessment
Summarization of the nurses thoughts concerning the given problem, analysis, explanation of why the plan might deviate from the usual management, prediction of probable results of nursing interventions
Plan
- Statement of the actual plan for the solution of management of the given problem
- Plans for collection of further data for reaching and treatment
- Plans for treatment, nursing care orders/objectives specific to treating the problem
- plans for teaching
Objectives of a nursing information system
- Describe, document and evaluate
OHN role
Nursing activities related legal requirements
Referrals
Users of health and safety services - Determine effectiveness and efficiency of health services
- Identify, document and evaluate the impact of nursing actions on benefits
Requirements of nursing information systems
- Ability to store all visits and activities
- Capability to generate reports on individuals, aggregates and all elements of database in timely manner
- Ability to be accessed at facility, corporate, different locations
- Interact with key da elements from other disciplines snd departments
- Timely and efficient manipulation of textual data
- Enables epidemiological studies across divisions of company
- Meets cost projections
- Provides protection of individual rights to confidentiality
- Easy to operate
- Accessed by individual identifie
- User education with routine maintenance and back up support
- Flexibility for changes with use
- Back up tape copying system
- Ability to do interactive searches
- Produces standard reports and forms
- Generates bar charts, graphs and statistical analysis
- Generates data for amiable periods of time
- Provides directories the hold all keywords, abbreviations or substitutes are used
- Ability to automatically flag abnormal values
- Adequate soce and memory for free text comments
Recommended procedures to ensure security of records/computer data
- Establish secure systems for both manual and computer data-password
- Provide for back-up systems in event of electrical failure, fire or flood
- Transfer records in a manner that safeguards privacy
- Provide confidentiality training
- Hire personnel to monitor security of computer records
- Install systems that prohibit others to change data
- Develop disciplinary procedure for violation of security
- Identify individuals requesting health record information
OSHA 300
- log of work related injuries and illnesses
- record all recordable injuries and diagnosed illnesses within 7 calendar days after you receive information about a case
OSHA 301
- injury and illness incident report
- one of the first forms you must fill out when a recordable work related illness or injury has occurred
OSHA form 300a
- summary of work related injuries and illnesses
- annual summary of information contained in log
- must be conspicuously posted from Feb 1- April 30 of the year following to year covered on the form
Amount of time OSHA recordkeeping forms must be kept
5yrs
Health-medical record retention requirement
30 years plus the duration of employment
Asbestos health-medical record retention requirement
20yrs
Lead health-medical record retention requirement
40yrs or duration of employment plus 20yrs, which ever is longer
Vinyl chloride health-medical record retention requirement
Not less than 30yrs
Report must be made to area OSHA director within —– after any accident which is fatal to —- or more employees or an accident requiring hospitalization of —- or more employees in any place of employment
8 hours
One
Three
How do you report incident
- in person at nearest OSHA office
- OSHA toll free hotline- 800-321-OSHA
