Documentation Flashcards

Which regulation governs the retention and access requirements for employee exposure and medical records in the workplace?

Answer: OSHA 29 CFR 1910.1020

OSHA 29 CFR 1910.1020 (Access to Employee Exposure and Medical Records) specifically governs how employers must preserve and provide access to occupational health records.

When a physician completes a Medical Examination Report (MER) for a commercial driver, which form number is used?

Answer: FMCSA Form MCSA-5875

The FMCSA Form MCSA-5875 is the official Medical Examination Report Form required for all DOT physical examinations of commercial motor vehicle drivers.

What is the correct action when an error is discovered in a completed paper occupational health record?

Answer: Draw a single line through the error, initial and date it, then write the correction nearby

The legally accepted method for correcting paper medical records is a single strikethrough line with initials and date, preserving the original entry while clearly noting the correction.

Under HIPAA's Minimum Necessary standard, when sharing occupational health records with an employer, which practice should be followed?

Answer: Disclose only the information necessary for the specific employment purpose

HIPAA's Minimum Necessary standard requires that only the information directly relevant to the specific, stated purpose be disclosed, not the entire medical record.

A Functional Capacity Evaluation (FCE) report primarily documents:

Answer: A worker's physical abilities and limitations relative to the demands of their job

An FCE objectively measures a worker's physical capabilities—such as lifting, carrying, and postural tolerance—and compares them against the functional demands of their specific job.

Which document must be completed before a third-party vendor can access an employee's occupational health records for wellness program administration?

Answer: A Business Associate Agreement (BAA) under HIPAA

Under HIPAA, a Business Associate Agreement must be executed with any third-party vendor that will access, store, or process protected health information on behalf of a covered entity.

In occupational health documentation, a 'near miss' incident report should be completed primarily to:

Answer: Identify hazards and prevent future injuries before they occur

Near miss documentation is a proactive safety tool that identifies potential hazards and system failures before they result in actual injury, enabling preventive corrective action.