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Health and medical record keeping

Updated: Feb 28, 2023

A health record must be kept for all employees under health surveillance. Records are important because they allow links to be made between exposure and any health effects. Health records, or a copy, should be kept in a suitable form for at least 40 years from the date of last entry because often there is a long period between exposure and onset of ill health. Here at Insight Health Screening we utilise eOPAS software, recognised as the market leader.

What information should be included in health records?

Employee details should include: 

  1. Surname

  2. Forename(s)

  3. Gender

  4. Date of birth

  5. Permanent address, including post code

  6. National Insurance number

  7. Date present employment started

Recorded details of each health surveillance check should include:

  1. The date they were carried out and by whom.

  2. The outcome of the test/check.

  3. The decision made by the occupational health professional in terms of fitness for task and any restrictions required. This should be factual and only relate to the employee's functional ability and fitness for specific work, with any advised restrictions.

The record should be kept in a format that can be linked with other information (eg. with any workplace exposure measurements).

If you are collecting a historical record of jobs or tasks completed during current employment, involving exposure to identified substances requiring health surveillance, it is useful to store them with this record.

For some exposures, all you need to do is set up and maintain records that may be viewed alongside other information, such as air sampling or biological monitoring results. This is the case, eg. with work involving:

  1. Known or suspected carcinogens.

  2. Machine made mineral fibres.

  3. Rubber manufacturing and processing, giving rise to rubber process dust and rubber fume.

  4. Leather dust in boot and shoe manufacture.

What health records should not contain

Health records are different to medical records in that they should not contain confidential medical information. Health records and medical records must therefore be kept separate to avoid any breaches of medical confidentiality.

Any personal medical information should be kept in confidence and held by the occupational health professional responsible for the health surveillance programme.

Medical records

Medical records are compiled by a doctor or nurse and may contain information obtained from the individual during health surveillance. This information may include clinical notes, biological results and other information related to health issues not associated with work. This information is confidential and should not be disclosed without the consent of the individual. 

The occupational health (OH) professional may obtain data as the result of an immunisation programme. This information will be provided to the employee and should not be given to the employer. It will be kept in confidence by the OH professional and should only be made known to the employer with the employee’s consent.

The doctor or nurse should only provide employers with information on fitness to work and any restrictions that may apply in that respect. Employees can have access to their own medical record through a written request under the Data Protection Act. These details can only be released to third parties, such as the employer, on receipt of the informed written consent of the employee, or by a court order.

Key Points

  1. A health record must be kept for ALL employees.

  2. Copies should be kept in a suitable form for at least 40 years from the date of last entry.

  3. Health records are different to medical records.

  4. Any personal medical information should be kept in confidence.

What can Insight do to help?

Here at Insight, we utilise eOPAS portal software, which is recognised as a market leader. Using clear, efficient processes to ensure compliance and help you maintain records. We offer Health Surveillance services which include a range of medicals and assessments. We offer Mobile Screening services with our fleet of vehicles manned by experienced staff.

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