Gold Standards in Occupational Health Record Keeping

Dr Lara Shemtob
5 days ago
2 min read

What happens if you—or someone else—want to access an occupational health (OH) record? Can employees request to view, amend, or redact their own records?

Maintaining high standards in occupational health record keeping requires compliance with both legislative requirements and professional standards. Here’s a breakdown of what this means in practice.

Legal standards: The role of GDPR in the UK

Occupational health records fall under the scope of UK GDPR and the Data Protection Act 2018. However, professional standards are layered on top of this which means there are additional aspects to data protection in a healthcare context

Right to erasure

While individuals generally have a right to request the erasure of their personal data, this right is less likely to apply in the OH context. Medical records are usually exempt because they are required to be maintained, for legal, clinical, or public interest reasons.

Right to rectification

Individuals can request that incorrect personal data be corrected. When translating this to healthcare, this means:

If a working diagnosis changes as new information emerges about someone’s health, the earlier (even if now incorrect) diagnosis remains part of the historical clinical record.
The new diagnosis should be clearly documented, but the earlier record should not be deleted if it accurately reflected the clinical view at the time.

Disagreement with clinical opinions

Individuals may disagree with the clinical opinions recorded in their occupational health records. While the disagreement can be documented, the opinion itself does not need to be altered or removed, provided it was made within the standards of professional practice.

Subject access requests

Under GDPR, individuals have the right to access their own data, including OH records, free of charge. Employers or OH providers must respond within one month.

There are exemptions to this with health data, including the serious harm test. This is when a healthcare professional is concerned that that complying with the right of access request would be likely to cause serious harm to the physical or mental health of any individual.

Third party requests

Access to information held within an individual’s OH record by someone else (e.g. employer, solicitor) must only occur with the individual’s explicit, informed consent, except in specific situations such as:

A court order.
Public interest concerns (e.g. risk of serious harm to others).

Professional standards in occupational health record keeping

High-quality clinical record keeping is essential for safe, ethical OH practice. This includes:

Documenting all clinically relevant information, even if sensitive.
Ensuring clarity and accuracy.
Limiting disclosure to when the individual gives consent, with clear professional standards in place around any breaches of confidentiality

Case study:

An employee shares a sexual health history with their OH clinician and asks for it not to be documented. While the clinician can limit what is shared with the employer, the full, accurate history should still be recorded in the clinical file, as it may be relevant to ongoing health assessments or care.