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Medical recordkeeping in an occupational health setting
1Croft-Taylor Consulting, LLC, 19-25 Prospect Ridge, Ridgefield, CT 06877, USA. mct26@columbia.edu
Abstract:
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.
Related Concept Videos
Purpose of Health Records I
Here's a breakdown of how health records serve these purposes:
Purpose of Health Records II
Legal Guidelines for Documentation
Methods of Documentation I: Source-Oriented Records
In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
Methods of Documentation II: POMR
Documentation in Long-Term and Home Healthcare Setting
Long-Term Care Facilities

