Content of the medical record

The health doctor fills out a medical record for each employee. It is meant to track the professional exposures and help the occupational physician to understand the relations between the state of health and his working conditions. 

Content of the medical record
Retention period of the personal record 

This content of the medical record is required by the French Health Authority ( called in French : HAS, Haute Autorité de santé)

Content of the medical record

A computer file is better.

Administrative informations 

Surname, married surname, forname , date of birth, addres, phone

Informations about previous and current jobs

• Previous jobs :
  areas of activity, professions, positions held, professionnal exposures.
• Current job :
  business name and address,
  area of activity of the company,
  contact details of the occupational physician and the occupational health service,
  employee’s own regular occupation, type of contract, date of takeover,
  working hours,
  description of the workstation (tasks, identified risks, individual and collective measures of prevention),
  adjustements ( in workstation and work conditions, occupational exposures, measures of prevention).

Informations about employee’s health

• Date, nature of the medical examination (pre-recruitement, periodical, reinstatment, etc)
• Personal medical history .
• Tobacco and alcohol consumption, other addictions.
• Current treatments.
• In case of exposure to hazardous reprotoxic substances : contraception, becoming pregnant.
• Vaccination status related with the professional exposure.
• Sick leaves since last medical examination  : date, duration, reasons
• Results of physical examination : presence of physical or psychological symptoms , if they are present : are they related to the working conditions ?
• Informations contained in medical documents provided by the employee which shoud be useful for its health’s monitoring.
• Results of paraclinical examinations (spirometry, chest x-rays, etc), value of biological exposure indicators (BEI), etc.
• Any opinion of a medical  expert about detection or monitoring of an illness which may be related with the working conditions.

Proposals and opinions of the occupational doctor

The occupational physician has to inform the employee about :

• Professional exposures :
  •  identified risks,
  • measures of prevention such as the PPE, Personal protective equipments.
• Is there or not a work-related disease 
• Certificate issued during the medical check-up (a report is filed by the occupational physician after each medical examination)
  
• Opinion’s doctor  :
  • does he need a second medical opinion (specialized medical consultation) ?
  • is a workstation layout necessary ?
  • what proposals does he have to improve the working conditions ?
• vaccines that requires its profession  ;
• medical surveillance proposed by the doctor : simple medical surveillance or strengthened medical surveillance in case of exposition to specific occupational hazards or strengthened medical supervision in case of particular personal situation.

 

Retention period of the personal record

The French Health Authority ( called in French : HAS, Haute Autorité de santé) recalls that there is no general rule about the retention period of the occupational medical record, however some specific rules define the retention of the record in case of exposure to the following hazards :

• Exposure to dangerous biological pathogens : record should be kept during 10 years after the end of the exposure and for up to 40 years in case of exposure to biological agents which cause diseases with long incubation period.
• Exposure to  CMR substances (Carcinogenic, Mutagenic and or toxic to Reproduction ) :  record should be kept during 50 years after the end of the exposure.
• In case of tasks with hyperbaric conditions :  record should be kept during 20 years after the end of the exposure.
• Exposure to the ionising radiations : record should be kept during 50 years after the end of the exposure.

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