Do your health systems’ clinics or service areas, keep the documentation of occupational health related services in a location other than the patient’s regular medical record? We do not have an occupational health clinic - but have small
general medical clinics with contracts with area employers to provide some limited services for their employees. Our clinics have been operating on the premise that these occupational health services could not go into the patients’ general medical record.
The need to do this is being questioned now – and I’ve been asked if there are any standards dictating where the occupational health services need to be documented/retained. OSHA’s medical record keeping standard does not appear to address how a medical provider/clinic
maintains occupationally focused services differently from other health services. I am thinking the service can go into the patient’s medical record – but since I don’t work with external occupational health services at this time – wanted to check with this
group. Are there any standards that would require keeping occupationally related services out of a patient’s general medical record? Thank you for your help.
Brenda Birkholz, MPH, RN, COHN-S
Manager, Employee Health
Hutchinson Health
1095 Hwy #15 S
Hutchinson, MN 55350
Ph: 320-484-4502
Fax: 320-484-4643