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Record keeping

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.

What information should be included in health records?

Individual, up-to-date health records must be kept for each employee placed under health surveillance. These should include details about the employee and the health surveillance procedures relating to them.

Employee details should include:

Recorded details of each health surveillance check should include:

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

If you are collecting an 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:

It is good practice to offer individual employees a copy of their health record when they leave your employment. If your company changes hands, consider offering the health record to the individual employee, and/or to the new occupational health service provider. Make sure that health records are stored securely.

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 the course of 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 (for example, blood titres or 'non responder' information). 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 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.