[Documenting occupation in the medical chart of a public hospital system: 2006-2010]

To describe the frequency of recording of a patient's occupation and/or employment status in the medical charts of a Barcelona hospital system by age, sex, department and type of medical record.

We reviewed the medical records of a random sample of 495 patients age 18 years and older, admitted between 2006 and 2010 in nine hospital departments (dermatology, pulmonary diseases, ophthalmology, oncology, otolaryngology, radiation therapy, rehabilitation, traumatology and urology). For each department and each year, 11 hard copy and 11 different electronic records were reviewed. In all cases we collected information on recording of occupation and/or employment status, age, sex and recording year.

57% of reviewed records were from male patients, 40% of the charts were hard copy and 60% were electronic. Overall, information on the patient's occupation and/or employment status was found in 32% of cases, more often for male patients and in the hard copy records. The rehabilitation department exhibited the highest completion rate (47%), whereas the ophthalmology department exhibited the lowest (16%).

Information on a hospitalized patient's occupation and/or employment status is low, being present in less than one-third of cases, which is consistent with previous studies conducted in Spain and elsewhere. Specific initiatives are needed to improve this important shortcoming.