Anyone who practices occupational medicine or nursing needs to know what injuries and illnesses must be recorded on an OSHA 300 Log and what makes them recordable (Exhibit 15–2). Many large employers use the OSHA 300 Log as a measure of safety and/or quality of medical care. It is common for managers to be evaluated on the injury rate in their plant and bonuses often depend on this rate. Employees may also have a financial stake in not getting hurt. There are often incentives for groups of workers that do not have any serious injuries during a specific time period.

This does not mean that physicians should collude with employees or the company to conceal the severity of an injury. The first duty of the physician is to provide all necessary and appropriate care to the injured worker. However, the physician should be cautious about providing care beyond what is necessary, particularly if it is only done to appease an angry patient.

The OSHA act requires that all work-related deaths and illnesses be recorded on the OSHA 300 Log, but it limits the recording of injuries to specific types of cases. The act states that all injuries must be recorded unless they are “minor injuries requiring only first aid treatment, and which do not involve medical treatment, loss of consciousness, restriction of work or motion, or transfer to another job.” In other words, an injury must involve at least one of these four conditions to be recordable.

Two of the four triggers are beyond the control of the medical care provider. If the worker lost consciousness from the injury it is recordable, even if no medical treatment is required. Also, if the employer chooses to move the worker to another job because of the injury or the treatment, that is their decision. It is the need for medical treatment and the restriction of work or motion that the treating nurse or physician can control.

The simplest condition for the physician to evaluate is the need for restriction of work or motion, but it is also the most contentious. Years of careful research by the National Institutes of Occupational Safety and Health have shown clearly that rest and/or splinting is not appropriate treatment for mild to moderate sprains, strains, or tendinitis. The appropriate treatment is antiinflammatory drugs and exercise. Unfortunately, the average worker thinks that the best thing for a sore back is a few days sitting in front of the television. Physicians should limit the use of rest, restrictions, or splinting to injuries that have clear signs (not just symptoms) of moderate to severe injury. This is good medicine not just good politics.

All restrictions should be very specific about the limits on activity and the time these limits will be in effect. A physician doing occupational medicine should never say, “Mr. Smith is on light duty.” The restrictions should say such limits as “no lifting over 20 pounds,” or “no typing,” or “no use of the left arm.”

The last trigger for recordability is that the injury requires medical treatment, not just first aid. This does not mean that seeing a doctor triggers recordability. It is the nature of the treatment, not who gives it, that makes an injury recordable. Because the distinction between first aid and medical treatment is vague, OSHA has established some specific guidelines.

The list is long, but there are some general rules that make sense. Second and third degree burns, fractures, and wounds that become infected or require surgical treatment such as sutures or debridement are severe enough that they should be recorded. In addition, sprains and strains that require physical therapy or repeated treatments past the first visit are requiring medical treatment, not just first aid.

Prescription medications are also clearly medical treatment. A worker can take over- the-counter ibuprofen without a prescription. This is not considered medical treatment even if he or she takes 800 mg three times a day. If a doctor writes a prescription for 800mg ibuprofen, the injury is recordable.

Physicians who do occupational injury care only occasionally should be careful about overtreating simple injuries and making them recordable. Prescription nonsteroidal anti-infalammatory drugs (NSAIDs), narcotics, antibiotics, and physical therapy should be reserved for injuries that are severe enough to warrant such treatment. If the physician gives a prescription just to appease a troublesome patient, the physician should note in the chart that the injury was not severe, but the medication or therapy was given for patient comfort. But remember, if the physician would not be comfortable explaining a narcotic prescription to the Drug Enforcement Administration (DEA) then it shouldn’t be given at all.

It is clear from this discussion of what makes an injury recordable that not all workers’ compensation injuries are recordable. The reverse is also true. Not all recordable injuries are covered under workers’ compensation. Many states do not require payment under workers’ compensation until an injury has limited the worker’s activity or required care for a specific number of days. A laceration that is sutured by the plant doctor is a recordable injury, but there may not be a workers’ compensation claim filed. In contrast, a worker with a strained back may be treated in an emergency room and given heat treatment, massage, Advil, and exercise instruction. This would be billed to the workers’ compensation insurance but it would not be recordable.

In summary, there are very specific rules about what injuries and illnesses should be listed on the OSHA 300 Log. Physicians and nurses who frequently treat work- related injuries should be familiar with these rules. The U.S. Department of Labor publishes Recordkeeping Guidelines for Occupational Injuries and Illnesses (O.M.B. No. 1218–0176), which answers most of the questions that arise.