Health records and medical confidentiality

Every worker who needs health surveillance should have a health record. Health records are important and useful because they provide a record of:

• work that has involved exposure to certain risks; and
• the outcome of previous health surveillance.

A health record should contain the following information:

• Name
• Gender
• Date of birth
• Permanent address
• Contact address
• National Insurance Number
• Date of starting current job
• A history of jobs that have involved exposure to specific substances or activities that require health surveillance. (Occupational health providers should attempt to record previous exposures, whether in the current job or previously)
• Date and results of any health surveillance. (The conclusions should only relate to fitness to work)

A health record is different to a clinical record and should not include confidential clinical data.

The employer should keep a health surveillance record irrespective of whether an employee is full or part time, permanent or on a temporary contract.

[back to top]

How long should health records be kept?

You should keep a health record as long as the person is employed by your company. You may need to retain health records for up to 50 years but this depends on good practice and specific legislation (eg asbestos). Also, ill-health effects may not emerge until long after a person leaves your employment.

[back to top]

What should I do if someone stops working for me?

It is good practice to provide them with a copy of their health record.

[back to top]

What information should not be kept in health records?

Clinical data that is used to make decisions on fitness to work is not held on this record. The occupational health service provider should keep the clinical data in confidence.

This clinical data can only be accessed either by the employee approaching your occupational health service provider under the Access to Health Records Act 1990, or by an employee giving written consent for their details to be released.

[back to top]

Confidentiality

If details of a medical nature are disclosed to you following written consent then you must retain the medical information but separate it from the health record. This is because the medical information is confidential to the employee and should not be disclosed to a third party.

Under the Data Protection Act 1998, you have to inform employees that you have a health record for them, and that they have a right to access that information and correct it.

• Health surveillance

[back to top]