Medical recordkeeping in an occupational health setting.

Abstract

Managing the complexity of medical recordkeeping in an occupational health setting has been compared to navigating a shadowy maze. Successful navigation requires knowledge-based clarity and direction. This article provides an overview of regulatory requirements related to medical recordkeeping in occupational health settings and highlights key medical record legislation and relevant practice standards. It discusses the importance of facility policies and procedures to recordkeeping compliance and identifies critical elements of these policies and procedures. The article identifies the range of documents included in medical recordkeeping in an occupational health setting, the primary determinants of the content, maintenance, and retention of medical records, and the medical recordkeeping tools and resources available to occupational health nurses. It provides answers to many frequently asked questions regarding recordkeeping.