Providers who care for work-related injuries must know the laws on recordkeeping in their state. These records are not always confidential like personal medical records. There is a long list of people who have statutory access to workers’ compensation or OSHA records. At a minimum, the patient, the employer, and the workers’ compensation insurance company have access to the records on the specific injury. In some states, the health department or other state agency also has statutory access. In some circumstances, the union may have a right to the information even if the patient is not a member. And, OSHA generally has access if it is a regulated workplace or a specific type of injury.
If you practice occupational medicine, make sure your medical records people know the rules and release information appropriately. Do not insist that the patient sign a release before complying with statutory requirements. If the patient is willing to sign a release, fine. If not, simply inform the patient that you must comply with the law and release the records.
If the patient wants to keep the records closed and not inform the company, then the patient must pay for the care out of his or her own pocket. They may not charge the care to their personal health insurance. Even the patient’s paying does not prevent access by state agencies and OSHA if they have a statutory right to see the records. In some states, this may not prevent access by others as well, particularly the employer. Also, public health reporting requirements apply regardless of who pays the bills.
Most states have very specific reporting forms for work-related injuries. Typically there are specific sections for the employer, the employee, and the physician. Copies of routine medical records may be acceptable from the physician or they may not. Most occupational medicine physicians prepare these forms as part of their regular medical recordkeeping. In addition, there may be specific OSHA records required. Do not do workers’ compensation care if you cannot comply with the recordkeeping requirements.
OSHA recordability and records retention requirements are a major consideration in occupational medicine practice and are discussed in detail later in the section.