Ethics Guidance for Occupational Health Practice 9th Edition - Book - Page 40
3.22. Care should be taken with portable electronic data storage devices.
Occupational health professionals should ensure that they take appropriate
advice from IT professionals and do not rely solely on their own knowledge of
data systems.
3.23. General examples of standards to be considered for records are:
Minimal abbreviations should be used.
Include the name, designation and professional registration (if applicable) of
the creator of the record.
Every record should have the name and date of birth of the worker.
Personal comments should be avoided.
The content should have sufficient details pertinent to the reason the record
was created. For example, a clinical record should contain sufficient clinical
information and the opinion provided by the occupational health professional.
The information within the note should justify the decision. Similarly,
administrative notes should contain the reason for the interaction and action
taken as relevant.
Every action should be recorded accurately and contemporaneously, including
interactions with the worker, interactions relevant to the work such as with the
worker’s employer, and those that do not involve direct interaction with the
worker, for example reviewing a test result.
Records should not be altered after creation and filing. If an error
is identified after creation and filing, the best practice is to add a new record to
explain the error and add the correct information.
3.24. Examples of standards to be considered for paper records are:
Records should be legible and preferably created in black or blue ink.
Use of colour coding should be restricted as it may be lost during black and
white scanning or photocopying.
Each page should be numbered and initialised by the person creating the paper
record.
Any deletions/corrections should be by use of single line cross over and dated
and initialised by the person creating the records.
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