Occupational Health Practice

For clinicians establishing or working in an occupational health practice, many protocols and procedures will depend on the practice situation (i.e. freestanding clinic, corporate clinic, large clinic network) and on the industry or industries being served. However, the following are important considerations for any clinician providing occupational health services:

• Review (or create) policies and procedures to assure compliance with OSHA standards as well as compliance with other certification and licensing bodies.
• Identify occupational health hazards, such as biological, chemical, physical, ergonomic and psychological, for all worker groups and industries being served.
• Consider these risks, along with OSHA regulations, when designing and performing worker examinations and medical surveillance.
• Implement preventive measures that address occupational health risks in your practice such a protecting workers from Bloodborne Pathogens and Hazard Communication.
• Understand applicable state and local regulations related to issues such as pharmaceutical and vaccine storage, workplace safety requirements and medical waste.
• Be familiar with the screening protocols, procedures and calibrations required for equipment used, such as spirometers and audiometers, and with the certification requirements for staff performing the testing.
• Integrate worker health and safety education into clinical practice whenever possible. Be aware of the health and safety training that employers provide to workers.

Evaluating Occupational Exposures and Injuries

Take a Work History

The occupational and environmental exposure history is the most important tool that clinicians have when evaluating a worker for a work-related injury or illness. Clinician knowledge of a worker's occupational history and job duties are vital when performing fitness for duty and medical surveillance examinations. Clinicians should take the time necessary to understand a worker's job duties, work environment and exposures.

When evaluating an injury, clinicians should take a detailed history from the worker to determine the mechanism(s) of injury and record the specific work tasks and ergonomic factors that may play a part in the injury. Important factors include number of hours worked per day, overtime, recent changes in job tasks or processes, tools used, environmental factors (such as temperature), previous work injuries, and exposures to chemical and biological hazards. Cultural factors within the workplace and the worker including his or her primary language should be recorded. A good resource is ATSDR's "Taking an Exposure History" which includes discussion and case studies of taking an occupational and environmental exposure history.

Get Safety Data Sheets

Clinicians may identify worker exposures by obtaining Safety Data Sheets or SDS's (previously referred to as Material Safety Data Sheets or MSDS's) for the substances workers are exposed to at their jobs. Under OSHA's Hazard Communication Standard, all employers must have SDS's on all hazardous chemicals in their workplace and must make them available to workers who are exposed. Clinicians who are evaluating a patient for potential work-related illnesses should ask the worker or the employer (with the worker's permission) for copies of the SDS for any chemical the worker comes into contact with during work. Clinicians can also request SDS's directly from manufacturers.

Clinicians in occupational settings should familiarize themselves with the first aid procedures outlined in the SDS, be aware of the nature of the training being delivered to workers, and participate in the training if needed to explain adverse health effects or first aid procedures. Exposure information listed on SDS's is helpful in considering workplace screening and surveillance programs. When evaluating exposed workers, clinicians have the right not only to request SDS's from manufacturers and employers but also to obtain proprietary ingredients not listed on the SDS due to trade secrets protection.

Medical Screening and Surveillance

Medical evaluations in occupational health practice range from clearances for specific job duties, such as using a respirator, to screening and surveillance programs for workers exposed to hazards, such as lead and asbestos. The goal of medical screening is to detect disease or clinical abnormality before an individual would normally seek medical care, particularly if early treatment may benefit the individual. Medical surveillance is the analysis of health information to look for problems that may be occurring in the workplace that require targeted prevention. Surveillance may be based on a single case or sentinel event, but more typically uses screening results from the group of employees being evaluated to look for abnormal trends in health status. Biological monitoring, which may be part of screening or surveillance examinations, is the assessment of chemical exposures through analysis of blood, urine or, in some cases, exhaled breath. OSHA requires medical surveillance and in some cases biological monitoring in some standards. OSHA's 2009 publication, Screening and Surveillance: A Guide to OSHA Standards is a quick reference guide to help locate and implement the screening and surveillance requirements of the OSHA standards. For more information, see OSHA's Safety and Health Topics page on Medical Screening and Surveillance.

Medical Records - Laws and Confidentiality

Clinicians work with a variety of records in occupational health. It is important to understand the differences between these records, the confidentiality issues involved and specific rules related to the records. Clinicians are familiar with personal medical records which include documentation of personal health care, routine preventive care, acute illness care, and care of chronic diseases. Laws that affect information collected in medical records include the Health Insurance Portability and Accountability Act (HIPAA), the Americans with Disabilities Act Amendments Act (ADAAA) and the Genetic Information Nondiscrimination Act (GINA). Individual states also have laws about the privacy and confidentiality of personal medical records.

Occupational health practices generate medical records that document care of work-related illnesses and injuries or that are specific to workplace requirements. These records may include medical and employment questionnaires, job descriptions, pre-placement examinations, medical surveillance examinations, biological and other screening results, occupational exposure evaluations, and workers compensation medical records. Employers may keep employee exposure records, including workplace hazardous exposure monitoring (i.e. noise levels, air monitoring), biological monitoring (i.e. blood lead level), analytical methodologies related to monitoring results, and/or safety data sheets (SDS's).

According to HIPAA, employers have access to some protected health information if the disclosure is required to comply with laws relating to workers' compensation. HIPAA also allows disclosure per the requirements of state or federal laws and regulations. Thus, clinicians should be mindful of confidentiality when recording patient information in occupational medical records. Occupational health clinicians regularly keep personal health information (i.e. medical conditions not related to work) separate from exposure records. Certain OSHA standards require employers to obtain written opinions from clinicians performing required medical surveillance examinations. These standards typically state that "the employer shall instruct the physician not to reveal in the written opinion specific findings or diagnoses unrelated to occupational exposure."

OSHA Requirements for Occupational Medical Records

OSHA's regulation, "Access to Employee Exposure and Medical Records" (29 CFR 1910.1020), requires the retention of occupational medical records for 30 years after termination of a worker for the purpose of providing access to the records for employees and their representatives after a worker has left employment. Both employee medical and exposure records must be retained. Employees must be given access to these records at no cost to them by the employer within 15 days of the request. For more information, see the OSHA publication Access to Medical and Exposure Records.

Recordkeeping - The OSHA 300 Log

OSHA's Recordkeeping regulation (29 CFR 1904) requires employers with more than ten employees (except those in certain low hazard retail, finance insurance or real estate industries) to document specific information about work-related illnesses or injuries on the OSHA 300 logs. Clinicians may be asked questions by employers to help them decide what should or should not be recorded on the log. All work-related injuries and illnesses that involve medical treatment beyond first aid must be recorded. In addition, all work-related fatalities must be recorded. Employers are required to report a work-related fatality to OSHA within 8 hours. Starting in January 2015, employers are also required to report all work-related in-patient hospitalizations, amputations and loss of an eye to OSHA within 24 hours. For more information, see OSHA's Injury and Illness Recordkeeping and Reporting Requirements page.

Physicians should be aware that the OSHA law prohibits employers from retaliating or discriminating against a worker for reporting an injury or illness. If a worker has been disciplined, punished, fired, demoted transferred, or retaliated against in any way for reporting the signs and symptoms of an injury or illness, they can file a complaint with OSHA at 1-800-321-6742. This type of complaint must be made to OSHA immediately (within 30 days).

Reporting a Dangerous Workplace

If the clinician determines that working conditions at a specific worksite are unsafe or unhealthy, the clinician should bring the conditions to the employer's attention. The clinician should be careful to preserve patient confidentiality in discussions with employers (see Ethics and Confidentiality in Occupational Health).

The clinician may file a complaint with OSHA concerning a hazardous working condition at any time. In an emergency, such as reporting an imminent life threatening situation, contact OSHA immediately using the toll free number:

• 1-800-321-OSHA (6742). TTY 1-877-889-5627. Do not send email. The toll free number is monitored 24/7.

Employers are responsible for reporting to OSHA within eight (8) hours after the death of any employee from a work-related incident or within 24 hours of any inpatient hospitalization, amputation, or eye loss as a result of a work-related incident.

The best source of immediate help is often the OSHA Area Office. Clinicians who work in occupational health and safety may wish to become familiar with the resources and the personnel at the local level.

Setting up a Safe Outpatient Office

Clinicians may have to establish policies and procedures to assure compliance with OSHA standards in their workplaces. One OSHA resource for this is Medical & Dental Offices A Guide to Compliance With OSHA Standards. The requirements in this pamphlet apply to medical and dental offices whether there are two or two hundred employees. Other helpful resources include OSHA's Safety and Health Topics Page on Healthcare and the OSHA Hospital eTool.

Workers' Compensation

While workers' compensation and OSHA are distinct, the following is important information for clinicians working in the field of occupational health, particularly those new to the field. Because each jurisdiction is different, clinicians should be aware of local policies and procedures. A list of state and federal agencies and their websites is available. In addition, workers' compensation for federal employees is provided under the Department of Labor, Office of Workers' Compensation Programs (OWCP), which includes programs for longshore and harbor workers, nuclear energy workers, and coal miners.

For confidentiality purposes, clinicians should be very careful to avoid recording non-work-related medical information in the workers compensation medical records. Workers compensation medical records should be kept separate from personal medical records.

Additional OSHA Resources

OSHA's Office of Occupational Medicine and Nursing (OOMN) includes board-certified occupational medicine physicians and occupational health nurses who provide OSHA with medical, nursing and public health expertise. Select areas of expertise include heat illness, bloodborne pathogens, workplace violence, occupational health surveillance, chemical exposures, ergonomics, recordkeeping and occupational health management.

OOMN also administers the following programs:

• OSHA's Occupational Medicine Elective
• OSHA's Graduate Nurse Internship Program

OSHA publications:

• All About OSHA provides a good overview of OSHA's mission, coverage and employer responsibilities under the Occupational Safety and Health Act of 1970. A shorter brochure is "OSHA At-A-Glance".
• OSHA's Workers' Rights pamphlet explains in detail workers' rights under OSHA, including specific information about who is covered under OSHA, workers' rights and employers' responsibilities, and filing an OSHA complaint. A smaller brochure, "We Are OSHA - We Can Help", is available in English, Spanish, Chinese and Vietnamese.
• OSHA publications are free and can be ordered online.

Additional Governmental, Academic, Clinical and Professional Resources

The National Institute for Occupational Safety and Health (NIOSH) is a federal agency that conducts scientific and medical research on workers' safety and health. At no cost to employers or workers, NIOSH can help identify health hazards and recommend ways to reduce or eliminate those hazards in the workplace through its Health Hazard Evaluation (HHE) Program.

• NIOSH funds a number of training programs throughout the country for nurses, physicians, industrial hygienists and safety professionals. The training programs are provided through Educational Resource Centers (ERC's).
• A searchable NIOSH bibliographic database of occupational safety and health publications, documents, grant reports, and other communication products.
• A question can be submitted to NIOSH on-line at their "Ask an Occupational Safety and Health Question " web page.

The Bureau of Labor Statistics (BLS) is the principal federal agency responsible for collecting and analyzing labor and economic information. BLS's Injuries, Illnesses, and Fatalities (IIF) program provides annual information on the rate and number of work related injuries, illnesses, and fatal injuries, and how these statistics vary by incident, industry, geography, occupation, and other incident characteristics.

The Agency for Toxic Substances and Disease Registry (ATSDR) is a federal agency under the Department of Health and Human Services focusing on environmental health concerns and toxicology. ATSDR is mandated to assess waste sites, provide public health consultations concerning specific hazardous substances, perform health surveillance, maintain registries, perform research on environmental health issues, develop and disseminate information to the public on hazardous substances, and do education and training on environmental health. ATSDR has a wealth of information on-line concerning the toxicology and health effects of many hazardous substances. Of particular interest to clinicians are:

• Detailed Toxicological Profiles on a number of substances.
• Shorter ToxFAQ's written for the lay public on many substances.
• Case Studies in Environmental Medicine - self-instructional texts for clinicians. Some are substance-specific and others are on a general environmental health topic. A number of the case studies provide continuing education credits.

The Association of Occupational and Environmental Clinics (AOEC) is a national network of clinics specializing in occupational and environmental clinical evaluation. Over 60 clinics, including many with ties to university teaching centers, are members. Some clinics also have specialized pediatric environmental units. AOEC also has a wide range of educational and guidance materials for clinicians.

The New York State Occupational Health Clinic Network is a state-based occupational health clinic network with clinics throughout the state of New York.  The clinics offer diagnosis, care and support services for workers with occupational injuries and illnesses.

The Migrant Clinicians Network (MCN) is a national, not-for-profit organization founded by clinicians working in migrant health. Over 1,000 clinics across the country are members of the network. MCN provides a wealth of information for clinicians and migrant workers.

The American College of Occupational and Environmental Medicine (ACOEM) is the professional organization for physicians specializing in occupational medicine. ACOEM has a number of resources for occupational health clinicians, including continuing education courses and conferences, clinical practice guidelines, position statements and publications.

The American Association of Occupational Health Nurses (AAOHN) is the professional association for nurses specializing in occupational health. AAOHN has a number of resources for occupational health nurses, including on-line educational courses, an annual conference, position statements and publications.

The American Industrial Hygiene Association (AIHA) is the professional association for occupational and environmental health and safety professionals. In addition to many resources, a national listing can be searched for consultants in industrial hygiene.

The American Conference of Governmental Industrial Hygienists (ACGIH) is a professional association for occupational and environmental health and safety professionals in the U.S. and abroad. ACGIH creates the Threshold Limit Values (TLV's) for chemical and physical hazards and Biological Exposure Indices (BEI's).

The American Society of Safety Professionals (ASSP) is a global association of occupational safety professionals. Safety specialists can be accessed through ASSP chapters across the U.S. ASSP produces a wide range of technical publications.

The American Public Health Association (APHA) is the oldest, largest and most diverse professional organization of public health workers in the United States. APHA members include nurses, doctors, epidemiologists, administrators, researchers, industrial hygienists, and safety professionals, among many others.

The Council of State and Territorial Epidemiologists (CSTE) is an organization of member states and territories representing public health epidemiologists. It also provides technical advice and assistance to partner organizations and to federal public health agencies such as the Centers for Disease Control and Prevention (CDC). CSTE promotes the effective use of epidemiologic data to guide public health practice and improve health.