# Presentation: 777919

## Management of Employee Health Record

**Godwin Odia, MBA,MPA,RHIA**
- Health Information Management Consultant
- Aberdeen Area Indian Health Service

## Objectives

- What is employee health record?
- Why employee health record?
- Documentation into employee health record
- Access to employee health record?
- Maintenance and retention of employee health record

## What is employee health record?

- Employee health record is a record of work related
- Treatment
- Examination
- Exposures to infections, illness and other substances of IHS employee

## What is employee health record?

- Any health related information received, created, maintained by IHS regarding an employee’s physical or mental condition in its capacity as an employer
- Pre-employment and employment physical
- Immunization records where required or recommended for job performance or condition of an employment
- Records of exposure to bodily fluids, chemicals and other substances
- Medical complaints related to work place injuries and illnesses
- Workers compensation retained record (OWCP), etc

## What is not employee health record?

- Counseling and counseling referral records
- Employee assistance records  - alcohol, drug abuse records
- Patient Health Records - non-work related

## Why employee health record?

- Prevent injuries and illness on the job
- Prevent and or reduce the spread of communicable disease
- Promote safe work environment
- Promote employee health and wellness
- Used for medico-legal reasons
- Comply with federal and other applicable laws

## Federal Laws relating to employee health

- Occupational Safety and Health Act (OSHA) 29 CFR 1910
- Family Medical Leave Act (FMLA) 29 CFR section 825
- American with Disability Act – 29 CFR subsection 1630.14(d) and 1630.16(f)

## Documentation into employee health record

- Records collected and/or created as a condition of employment or recommended by IHS to its employees in its capacity as an employer
- Treatment
- Physical exam, periodic physical includes eye, dental exam
- Light duty medical documentation
- Medical care recommended by IHS

## Documentation into employee health record

- Written evaluation, diagnoses and opinions by health care providers generated in the course of treatment of an IHS employee for work related injuries and illnesses
- Records documenting work related injuries and illness
- Employee immunizations
- Immunization refusals – required and recommended immunization are documented in the employee health record

## Documentation into employee health record

- IHS retained files relating to OWCP claim - considered part of employee health record
- Case filed with OWCP is not part of the employee health record

## Consent Form	

## Documenting Refusal

## Access to employee health record

- Covered by government wide Privacy Act but not by HIPAA.  Therefore, confidentiality of the individual is protected
- Access limited to:
- Employee health staff
- Chief MIS or custodian of record
- Individual to whom the information pertains (Limitations may apply)

## Use and Disclosure of employee health record

- Records may be used or disclosed to the following individuals without the need for authorization:
- Federal and state official processing workers compensation claims
- Government officials investigating IHS compliance with employee health record laws
- Statistical data of employee immunization program to appropriate HHS employees and other Federal officials in support of IHS compliance program
- Appropriate IHS employees for defense against law suits

## Use and Disclosure of employee health record

- IHS may use and disclose the information from ADA medical examination to:
- Appropriate staff for accommodating and determining work restrictions of an employee
- Government officials investigating ADA compliance
- Emergency medical personnel

## Use and Disclosure of employee health record

- Any other use or disclosure that does not meet the above, an authorization is required
- Authorization must meet the same elements as a regular authorization for release of medical information

## Maintenance of employee health record

- Records must be kept in a secured location
- Separate from other records such as regular medical or personnel record
- Must be initiated as soon as employee is hired
- Transfers with employee to another location

## Crossover Records

- Under certain conditions, employee patient health record may cross over to become part of employee health record such as
- OWCP retained files
- Disability claim
- Immunization record

## Retention of employee health record

- Duration of employment plus 30 years
- Exposure records – 30 years
-    OSHA must be notifies three months prior to end of retention period before destruction of records

## Questions?

- Contact information
- 	Godwin Odia, MBA,MPA,RHIA
- 	605-226-7237
- 	Godwin.Odia@ihs.gov