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Recording an injury when treatment is prescribed or declined

Summary An employer asked how to log an injury when doctors gave conflicting views and the worker declined treatment. OSHA said the case should be judged by what occurred, including a prescription from the worker's physician. It also said an offer of medical treatment made the case recordable even if the worker refused it; OSHA now archives the letter.
Document
Federal opinion letter
Agency
Occupational Safety and Health Administration (OSHA)
Document number
1996-12-09
Date issued
December 9, 1996
Status
Archived by the agency
OSHA labels this an archive document and warns that it may no longer represent OSHA policy.
Status last verified October 9, 2026
Topics
Workplace Safety OSHA 1904 Recordkeeping
Source
View the official document

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The current status of this document is unclear
OSHA labels this an archive document and warns that it may no longer represent OSHA policy. It may no longer reflect the agency's current position. Treat this page as historical context, not current guidance, and verify current law before relying on anything here.
About this page: The full text below is the official document from Occupational Safety and Health Administration (OSHA). Ezel adds the plain-English summary and tracks the document's status. The official source linked on this page is authoritative for any reliance.

NOTICE: This is an OSHA Archive Document, and may no longer represent OSHA Policy. It is presented here as historical content, for research and review purposes only.

December 9, 1996
Richard Berkes
Manager of Safety & Health
Southwark Metal Manufacturing Co.
[Recipient address omitted]
Dear Mr. Berkes:
Thank you for your letter dated November 6, requesting an interpretation regarding the recordability of a work related injury. Decisions made for OSHA injury and illness recordkeeping purposes are not based on hindsight, but must be based on what actually occurred. When an employer has conflicting medical information regarding the diagnosis and corresponding treatment of an injury or illness, he/she must evaluate the case based upon what actually happened. Because the employee's personal physician issued the prescription of Fiorcet for the employee's condition, the case must be recorded based on the fact that the employee received medical treatment.
Furthermore, in your description of the incident, you stated that the employee was offered medical treatment which was declined at that time. For OSHA injury and illness recordkeeping purposes, a work related injury is recordable if medical treatment is provided or should have been provided. If a medical professional offered medical treatment to the employee, it makes the case recordable. It is irrelevant that the employee refused the medical treatment. The case should be recorded.
I hope you find this information useful. If you have any further questions, please contact us at Area Code (202) 219-6463.
Sincerely,
Bob Whitmore
Chief
Division of recordkeeping Requirements

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