EMPCO Documentation 2 — Questions and Answers
Question 1: When documenting a pre-employment physical examination, which element is MOST critical to include for occupational health purposes?
- Employee's personal hobbies
- Job-specific physical demands and whether the applicant can meet them (Correct answer)
- Applicant's previous salary history
- Interviewer's personal observations about appearance
Correct answer: Job-specific physical demands and whether the applicant can meet them
Pre-employment documentation must link medical findings to the specific physical demands of the job to be legally defensible and occupationally relevant.
Question 2: Which form is typically used to document an employee's consent to share medical information with an employer under HIPAA?
- OSHA Form 300
- Authorization for Release of Medical Information (Correct answer)
- FMLA Designation Notice
- Workers' Compensation First Report of Injury
Correct answer: Authorization for Release of Medical Information
An Authorization for Release of Medical Information is required under HIPAA before a healthcare provider can share protected health information with an employer.
Question 3: In occupational health documentation, what does the abbreviation 'FFD' stand for?
- Full Functional Diagnosis
- Fit for Duty (Correct answer)
- Federal Form Documentation
- Final Findings Disclosure
Correct answer: Fit for Duty
FFD stands for Fit for Duty, which refers to the evaluation and documentation determining whether an employee can safely perform their job functions.
Question 4: A medical examiner completing DOT physical examination documentation must retain exam records for a minimum of how many years?
- 1 year
- 3 years (Correct answer)
- 5 years
- 10 years
Correct answer: 3 years
DOT regulations require medical examiners to retain physical examination records for a minimum of 3 years from the date of examination.
Question 5: Which section of an occupational health record documents the employee's self-reported medical history?
- Assessment
- Plan
- Subjective (Correct answer)
- Objective
Correct answer: Subjective
In SOAP note format, the Subjective section captures the patient's own account of symptoms, history, and concerns.
Question 6: When an employee disputes information recorded in their occupational health file, what is the appropriate first step?
- Delete the disputed entry immediately
- Allow the employee to submit a written statement of disagreement to be filed with the record (Correct answer)
- Ignore the dispute unless it involves a legal claim
- Transfer the file to another facility
Correct answer: Allow the employee to submit a written statement of disagreement to be filed with the record
Employees generally have the right to submit a written statement disputing information in their health record, which is then attached to the original documentation.
Question 7: Which document type provides the employer with work restrictions without disclosing the employee's underlying medical diagnosis?
- Full medical report
- Functional Capacity Evaluation
- Work Status/Restriction Form (Correct answer)
- OSHA 300 Log entry
Correct answer: Work Status/Restriction Form
A Work Status or Restriction Form communicates only the functional limitations relevant to employment, protecting medical privacy while informing the employer.
EMPCO Documentation 2
When documenting a pre-employment physical examination, which element is MOST critical to include for occupational health purposes?