Medical-record retention versus injury-log retention

OSHA archive notice: "This is an OSHA Archive Document, and may no longer represent OSHA Policy. It is presented here as historical content, for research and review purposes only."

June 7, 1999

Kenneth B. Lieberman
Regulatory Compliance/ Accident Specialist
Niagara Mohawk
[Recipient address omitted]

Dear Mr. Lieberman:

Thank you for your April 24, 1999 letter to the Occupational Safety and Health Administration's (OSHA's) Directorate of Compliance Programs (DCP). As per your request, we are sending this letter as a follow-up to our phone conversation on May 3, 1999. We apologize for the delay and hope that this letter will serve as a more comprehensive review of your concerns relating to employee medical record retention, 29 CFR 1910.1020, "Access to Employee Exposure and Medical Records", and 29 CFR 1904, "Recording and Reporting Occupational Injuries and Illnesses". Your questions are outlined below, followed by OSHA's interpretation.

1. If an OSHA form 101 (or equivalent) and/or a doctor's/hospital's medical report is completed, and the injury/illness requires more than first aid, does this qualify as an employee medical record?

According to 29 CFR 1910.1020, paragraph (c)(6)(i), a medical record can contain any documentation of the health status of an employee "which is made or maintained by a physician, nurse, or other health care personnel or technician." This may include medical and employment questionnaires or histories, results of medical examinations, laboratory tests, medical opinions, diagnoses, progress notes, first aid records, treatments, prescriptions, and medical complaints.

Documentation exempted from inclusion into an employee's medical records is clearly defined in paragraph (c)(6)(ii) of the standard and includes information relating to worker injury or illness not made or maintained by a healthcare professional, but rather by a shift supervisor or the worker involved. Since your company, Niagara Mohawk, uses a New York State injury/illness reporting form as your OSHA 101 equivalent and it is commonly completed and maintained by a shift supervisor or other related professional, not a healthcare professional, it would not qualify as a medical record.

2. If so, and if we maintain these records separately from our medical program, and these records are accessible by employee name/other direct personal identifier via our insurance carrier, what is the retention period required by 29 CFR 1910.1020?

Regarding the retention period for records of injuries and illnesses, 29 CFR 1904.6 "Retention of Records", states that OSHA forms 200, 100, 101, and 102, or their equivalents, need to be "retained in each establishment for 5 years following the end of the year to which they relate." After a period of retention spanning five (5) years, it is no longer the responsibility of the employer to maintain these records. In addition to injury and illness logs, and with specific regard to individual employee medical records, you were correct in your interpretation that these should be preserved for "at least the duration of employment plus thirty years." Exceptions to this clause may be found in 29 CFR 1910.1020, paragraph (d)(1)(i).

Thank you for your interest in employee safety and health. We hope that you find this information useful. If you have any further questions or concerns, please feel free to contact OSHA's Office of Health Compliance Assistance at (202) 693-2190.

Sincerely,

Richard E. Fairfax
Director
Directorate of Compliance Programs