Objectives In any clinical speciality, the collection of accurate clinical information is a pre-requisite to providing high quality clinical care. Structured medical records can improve measures of performance and outcome in clinical care. In the United Kingdom (UK) record keeping standards have been developed for hospital medical records but none are available for occupational health services (OHS). This project reviewed the available evidence to develop generally applicable record keeping quality indicators (QI) for OHS.
Methods The results of three comprehensive UK literature reviews on record keeping standards were examined. Studies with direct or indirect relevance to the OHS setting were included. Evidence statements on medical record keeping were extracted. Bias, outcome measures and OHS implications were evaluated. Candidate QI were mapped against the results of a two-stage national consensus exercise on record standards, and suitable QI were developed.
Results 84 publications were included in the review, 22 were selected for full text appraisal. Performance improvements were shown with general structured assessment forms in seven publications and with context specific forms in 12 publications. No specific studies based in OHS were retrieved; however one publication was relevant to occupational health care. Following critical appraisal of the studies and the mapping process, four generally applicable record keeping QIs, with the headings “findings”, “treatment”, “assessment, and “advice” were developed.
Conclusions General and context specific record keeping standards have been shown to improve the quality of care in other medical specialities. We have developed four general record keeping QI for use in OHS. These indicators are applicable across all employment sectors. The indicators will be incorporated into a national UK clinical registry for OHS. Further work will be done to validate these QI in practice. Context specific record keeping indicators should be developed in occupational medicine.