Occ health: Occupational health records

OCCUPATIONAL HEALTH RECORDS

Medical records are kept by OMPs and ONPs on medical and occupational health issues of the employees. The National Health Act, (Act 61 of 2003) provides that persons in charge of health establishments must ensure that health recods are kept securely. There must be control over proper disclosure to third parties. An interesting note is that a health care practitioner may make a note retrospectively to clinical notes, but the practitioner must indicate the date the addition was made

INVASION OF PRIVACY
Although the practitioner may be consulting healthy employees and not overtly sick patients, the rules of privacy still aplies. Employees have the right to seclusion of their private lives which includes not being exposed to intrusion by others. The POPI Act has the function of protecting the individual’s and the organisation’s integrity

THE PROTECTION OF PERSONAL INFORMATION ACT (POPI ACT)
The purpose of the POPI ACT is to ensure that all South African institutions conduct themselves in a responsible manner when collecting, processing, storing and sharing another entity’s personal information by holding them accountable, should they abuse or compromise personal information in any way. Employee’s information is seen as “precious goods” and protects the employee as the owner of of personal information certain rights of protection. Employees must sign consent if their administrative information is going to be shared with third parties. Administrative information of employees may only be shared for valid purposes. Unauthorised persons may not have access to to administrative nor clinical information. Information storage facilities must be safe from theft or compromise

Administrative information that must be safeguarded includes
– ID or passport number
– Date of birth and age
– Phone numbers
– E-mail addresses
– On-line messaging identifiers
– Physical addresses
– Gender, race and ethnic origin
– Photos, voice recordings, video footage, biometric data
– Criminal records
– Private correspondence
– Religious or phylosophical belief or political opinions
– Employment history and salary information
– Education information
– Membership to organisations and unions

Medical ethics and medical record-keeping go hand in hand. The ethical principles that guide medical practitioners are
– Respect for autonomy; this includes the decision-making capabilities of autonomous persons. It also includes enabling persons to make informed decisions which forms the basis of informed consent and respect of confidentiality
– Beneficience (doing good); the practitoner should act in such a way that it benefits the patient. This includes the balancing of benefits of treatment against risks and costs
– Non-maleficience (doing no harm); “First do no harm” is a crucial pillar of all medical ethics. All treatments involve some possibility of harm, even if minimal. The harm should not be disproportionate to the benefits of treatment.
– Justice; patients should be tteatedd with fairness and equitability

ARCHIVING OCCUPATIONAL HEALTH RECORDS

Occupational health records should be kept for the following time period

IHE forms (Initial health examination)                   3 years
Primary health care notes (without exposure data) 6 years
IOD (injury-on-duty)   10 years
Fitness for work documentation              10 years
Hazardous chemical substances exposure cases             30 years
Lead exposure cases    40 years
Hazardous biological exposure cases                             40 years
Noise expsoure cases   40 years
Mine workers (e.g. at stone quarries)                       40 years
Occupational disease    40 years
Asbestos exposure        50 years

Access to information

Definition
The right to access to information means that people have the right to request and retrieve certain information held by state and private bodies. The Constitution of the Republic of South Africa 1996, states that every citizen has the right to access of any information held by the state. These rights are imlemented by the Promotion of Access to Information Act (Act 2 of 2000). The custodians of this information are the information officers and in the private sector, the head of private bodies

Occupational health personnel must protect confidentiality of staff and not release information to third parties (e.g. employers, insurance companies, lawyers or trade union representatives) without the employee’s direct consent

Exceptions are
– official court orders
– where third parties are endangered

The National Health Act allows disclosure for legitimate purposes by health care workers where such disclosure is in the best interest of the public