- AAOHN Journal
- December 2010 - Volume 58 · Issue 12: 524-533
Managing the complexity of medical recordkeeping in an occupational health setting has been compared to navigating a shadowy maze. Successful navigation requires knowledge-based clarity and direction. This article provides an overview of regulatory requirements related to medical recordkeeping in occupational health settings and highlights key medical record legislation and relevant practice standards. It discusses the importance of facility policies and procedures to recordkeeping compliance and identifies critical elements of these policies and procedures. The article identifies the range of documents included in medical recordkeeping in an occupational health setting, the primary determinants of the content, maintenance, and retention of medical records, and the medical recordkeeping tools and resources available to occupational health nurses. It provides answers to many frequently asked questions regarding recordkeeping.
ABOUT THE AUTHOR
Dr. Thompson is Researcher/Consultant, Croft-Taylor Consulting, LLC, Ridgefield, CT.
The author discloses that she has no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
The author is not an attorney; therefore, this article is not meant to provide legal advice and should not be construed as a legal opinion.
Address correspondence to Margaret C. Thompson, PhD, RN, COHN-S, FAAOHN, Croft-Taylor Consulting, LLC, 19-25 Prospect Ridge, Ridgefield, CT 06877. E-mail: firstname.lastname@example.org.
Received: February 27, 2010
Accepted: September 23, 2010
Posted: November 23, 2010