NHS occupational health departments still have some way to go in ensuring they are meeting compliance standards on record keeping, according to the first national clinical audit on the subject.
The audit, by the Royal College of Physicians’ Health and Work Development Unit (HWDU), concluded that there was incomplete compliance with standards on record keeping but that electronic records were generally better quality in terms of legibility and completeness of identification.
It recommended that OH departments invested in suitable electronic record systems that are secure and comply with NHS information governance standards.
Those with paper-based record systems should investigate simple changes that would increase compliance for recording the patient’s name and date of consultation on each side of paper, and the author’s name and designation at least once on the record.
Regardless of whether records are paper or electronic, clinicians should record consent under the Access to Medical Reports Act before they requested a report from another clinician and document carefully that copies of any reports to managers had been offered to the patient.
OH providers should review practices and develop mechanisms for service improvement, including investing in education and training, sharing good practice, improving dialogue with OH software system providers and developing action plans.
The HWDU has produced a list of the standards that will now be circulated to all occupational health services working with the NHS in England, and will also be placed on the HWDU website.