Documentation Flashcards

Under the ADA, what must an employer do with medical documentation obtained during a post-offer employment examination?

Answer: Store it in a separate, confidential medical file

The ADA requires that medical information collected during employment examinations be maintained in separate confidential medical files, apart from general personnel records.

What is the primary purpose of an Exposure Incident Report in occupational health documentation?

Answer: To record details of a worker's contact with bloodborne pathogens or hazardous substances

An Exposure Incident Report documents the circumstances, timing, and nature of a worker's exposure to bloodborne pathogens or hazardous chemicals for medical follow-up and OSHA compliance.

When documenting a work-related injury for OSHA recordkeeping, which criterion determines if the case must be recorded on the OSHA 300 Log?

Answer: Injuries requiring more than first aid treatment, days away from work, restricted duty, or medical transfer

OSHA requires recording work-related injuries and illnesses that result in days away from work, restricted duty, job transfer, loss of consciousness, or medical treatment beyond first aid.

Which component is mandatory in a chain-of-custody document for occupational drug testing?

Answer: Specimen ID number, collection date/time, and signatures at each transfer point

Chain-of-custody documentation must track the specimen through every transfer using a unique ID, timestamps, and signatures to ensure integrity and legal defensibility.

A medical surveillance record for a worker exposed to lead must be retained for a minimum of:

Answer: 30 years

OSHA's lead standard (29 CFR 1910.1025) requires medical surveillance records for lead-exposed workers to be retained for at least 30 years.

In the context of EMPCO medical documentation, what does a 'clearance letter' communicate to the employer?

Answer: That the employee has been medically evaluated and is cleared to perform the specified job functions

A clearance letter confirms that a medical evaluation has been completed and the individual meets the health requirements for the specified position or task, without disclosing medical details.

Which of the following best describes the 'objective' section in an occupational health SOAP note?

Answer: Measurable, observable findings such as vital signs, physical exam results, and test values

The Objective section contains quantifiable, reproducible clinical findings observed or measured by the examiner, such as blood pressure, test results, and physical examination findings.