What this is
What is an occupational health case record?
What is an occupational health case record?
It is the master record for a single health case, opened when a work-related injury, work-related ill health, non-work condition affecting work, or a surveillance finding first requires management. It states who the case belongs to, who manages it, what access restrictions apply, and which downstream records exist, without holding a clinical narrative.
How does the case record differ from the records it points to?
The case record is the thread; the restriction record, modified duty plan, referral and closure record are the entries on it. It answers whether a case exists, who owns it and what it is about functionally, and should not contain content that belongs in those other records.
Who can see an occupational health case record?
Occupational health, by default, with access restricted from the rest of the organisation. A supervisor is entitled to know the effect on work and any restriction, not the diagnosis, and the confidentiality fields exist to prove that boundary was set deliberately.
Scope
When is an occupational health case record required?
This is the case-opening and index record, not the place to document any step of managing the case. Its most common misuse is being treated as a running file that absorbs whatever occupational health writes, rather than a pointer to records built for that purpose.
Use this template when
- A work-related injury, work-related ill health, non-work condition affecting work, or surveillance finding first requires case management
- A new case is needed; each one gets its own ID in the form HCASE-2026-000
- A case needs to exist before a referral, restriction or plan can be linked to it
- A linked record needs the case to exist first, since referral, plan and restriction all carry the case ID forward
- The confidentiality boundary needs to be set at the point the case opens, not decided informally afterwards
Do not use it for
- Work Restriction Record, which states what the worker can and cannot do while the case is open, rather than that the case exists
- Modified Duty Plan, which sets out the temporary duties themselves, once the case record has identified they may be needed
- Case Progress Review, which checks the case against its expected timeline partway through, rather than opening it
- Case Closure Record, which records the outcome and any lasting restriction when the case ends
- Claim Support Record, which holds the information supporting a workers' compensation claim, kept separate from the index
Compliance mapping
Which Privacy legislation requirements does this satisfy?
The case record's basis is privacy legislation rather than a safety management standard, so its defensibility rests on data protection reasoning: what condition permits processing, who may see it, and what was actually recorded.
| Clause | Requirement | Where it lands |
|---|---|---|
| UK GDPR art.9(2)(h) | Processing special category health data is permitted for occupational medicine and assessment of working capacity | Header |
| DPA 2018 Sch.1 Part 1 para 1 | Health data condition for employment purposes, requiring an appropriate policy document | Header |
| UK GDPR art.9(2)(a) | Explicit consent as the separate basis for a specific disclosure, distinct from the basis for holding the data | Header |
| UK GDPR art.5(1)(c) | Data minimisation, so only what is adequate and relevant to the stated purpose is recorded | Situation |
| ISO 45001 cl.5.4 | Consultation and participation of workers in matters affecting their health, including their own case | Support in place |
| ISO 45001 cl.6.1.2.1 | Hazard identification proactive and ongoing, extended by pattern to other workers exposed to the same condition | Prevention |
| MHSWR 1999 reg.3 | Suitable and sufficient risk assessment, reviewed where new information shows it is no longer valid | Prevention |
What it does not cover
- Work Restriction Record, which states what the worker can and cannot do while the case is open, and is the record a supervisor should be given.
- Modified Duty Plan, which sets out the specific temporary duties a returning worker performs, once a need for them is identified.
- Case Progress Review, which checks the case against its expected timeline while it remains open.
- Case Closure Record, which records the outcome and any lasting restriction at the point the case ends.
- Root cause investigation, which belongs in its own RCA record once the case flags that others may be at similar risk.
Global
Occupational Health Case Record requirements by country
The duty to protect occupational health data is close to universal in substance, but the instrument doing the protecting differs enough to change what a case record has to prove.
ADA 29 CFR 1630.14(c) and 42 USC 12112(d)(3)(B)
Medical information from an employment-related inquiry must be kept in separate files, with disclosure to supervisors limited to restrictions and accommodations.
The separation this template's confidentiality fields enforce is the statutory floor, not good practice; a case record mixing in clinical detail is itself the violation.
UK GDPR art.9; DPA 2018 Sch.1 Part 1
Health data processing for occupational medicine has a lawful condition without needing consent, but a policy document and access restriction still have to be demonstrable.
A regulator will ask who could see the record and why, and the access-restricted field only answers that if it reflects actual system permissions, not intention.
ISO 45001 cl.5.4 and cl.6.1.2.1
Worker consultation and hazard identification extended to others exposed sit alongside the data protection duty rather than replacing it.
A certification audit checks whether a case fed the prevention loop, a different question from whether it was held confidentially, and both have to be true.
How to complete it
How to complete an occupational health case record, step by step
Every confidentiality field can score a perfect three and the case can still be handled badly. The judgement calls sit in what gets typed into the fields not marked confidential.
Full duties, modified duties, phased return or absent is the correct level of detail. The temptation is to add why, in the assessor's own words, and that sentence is where the diagnosis usually ends up. Anything more belongs in the restriction record or the referral, not a free-text elaboration on the case index.
Worker consent obtained governs sharing the fitness outcome with the employer. Occupational health can hold the underlying health data without it, under the occupational medicine condition. A No should stop the outcome reaching the line manager; it does not mean the case cannot be managed.
Root cause investigated and others at similar risk sit in the same section regardless of case type. Skipping them because a case is ill health rather than an injury misses the pattern these fields exist to catch, since one case tied to a task usually means several people share the exposure.
Worker preference respected is easy to skip once occupational health and the line manager have already agreed a plan. A case record with no evidence the worker was asked is harder to defend after a return fails, whatever the outcome turned out to be.
What auditors find
Most common occupational health case record findings
The case record almost always exists once a case is open. The findings concern what leaked into it that should not have, and what the prevention section quietly skipped.
| Finding | Clause | What fixes it |
|---|---|---|
| Diagnosis or treatment detail entered into the effect on work or job demands fields. | UK GDPR art.5(1)(c) | Restrict these fields to a function statement; route clinical narrative to occupational health only. |
| Access restricted to occupational health answered Partly, with no remediation before the case closed. | DPA 2018 Sch.1 Part 1 para 1 | Treat Partly as an open action with an owner and deadline, not an acceptable final state. |
| Consent obtained recorded once at opening and never revisited when the plan changed materially. | UK GDPR art.9(2)(a) | Re-confirm consent whenever the information shared with the employer changes. |
| Prevention section left blank on ill-health and surveillance cases, populated only for injuries. | ISO 45001 cl.6.1.2.1 | Apply root cause and others-at-similar-risk questions to every case type, not injuries only. |
| Worker preference respected marked No with no note on why or evidence of the conversation. | ISO 45001 cl.5.4 | Require a brief note whenever preference is not respected, naming what overrode it. |
| The case record used to store the full accommodation plan instead of raising its own records. | DPA 2018 Sch.1 Part 1 para 1 | Keep the case record to references only; plan and restriction content belong elsewhere. |
Case in point
Case in point: the confidentiality fields that scored perfectly
A logistics operator opened a case for a driver reporting work-related ill health. Clinical detail held separately, access restricted to occupational health, and worker consent obtained were all answered Yes. The case manager, an occupational health nurse, then completed effect on work with a summary that included the specialist's diagnosis and the medication prescribed, because that was the information in front of her and nothing stopped her writing it there.
Six months later the case was pulled for an unrelated grievance investigation. The investigating manager, who had access to case records but not clinical files, read the diagnosis directly from a field the confidentiality design had never anticipated being used that way. The access controls had worked exactly as configured; the content simply ignored the boundary they were built around. The fix was a rewritten situation section restricted to function, with a link to the occupational health file for anything more.
The template
The template, field by field
The form exactly as it installs. Every field, option, score and conditional rule is editable, and the links to other templates come with it.
4 sections
- Reference
- HLT-016
- Archetype
- Record
- Record ID
- HCASE-2026-000
- Scoring
- Not scored
- Direction
- n/a
- Singleton
- No
- Basis
- Privacy legislation
- Links
- Links Worker, Case
- Tags
- Health, Case
- Sections
- 4
- Fields
- 49
- Follow up fields
- 4
- Repeating sections
- 0
- Links out
- 10
Header
19 fieldsCase ID*
Auto sequence. Format OHC-2026-000.
The record's own ID. Other templates point at this value.
Status*
Drives who this goes to next.
- Planned2 pts
- In progress2 pts
- Complete3 pts
- Deferred0 pts
- Open0 pts
- Closed3 pts
- Overdue0 pts
Date and Time*
Completed By*
Site*
Site ID*
Format SITE-000.
Links to FDN-001 Site ID
Worker*
Person ID*
Format PER-0000.
Links to FDN-003 Person ID
Record Confidentiality
Clinical detail stays with occupational health. Management receives a fitness outcome and any restrictions, never a diagnosis. Restrict access to this template accordingly.
Clinical Detail Held Separately*
- Yes3 pts
- No0 pts
Access Restricted To Occupational Health*
- Yes3 pts
- Partly1 pt
- No0 pts
Worker Consent Obtained*
Consent to share the fitness outcome with the employer. Withdrawal is the worker's right.
- Yes3 pts
- No0 pts
Case ID 2
The injury or ill health event this case follows, where one exists.
Thread key. Every record in this chain carries this value
Parent Type
What kind of record this follows.
Parent ID
The reference of that record.
Immediate predecessor record
Raised Date*
Case Type*
Work related injury, work related ill health, non work related condition affecting work, or surveillance finding.
Case Opened*
Case Manager*
Situation
8 fieldsEffect On Work*
Full duties, modified duties, absent, or phased return. No diagnosis recorded.
- Full duties3 pts
- Modified duties1 pt
- Phased return1 pt
- Absent0 pts
Absence Started
Expected Duration
- Under 2 weeks3 pts
- 2 to 6 weeks2 pts
- 6 weeks to 3 months1 pt
- Over 3 months0 pts
- Indefinite0 pts
Task
Job ID
Format JOB-000.
Links to FDN-004 Job Task ID
Job Demands Documented*
- Yes3 pts
- Partly1 pt
- No0 pts
Adjustments Possible In Current Role*
- Yes3 pts
- Some1 pt
- No0 pts
Alternative Duties Available*
- Yes3 pts
- Limited1 pt
- No0 pts
Support in place
9 fieldsContact Maintained During Absence*
Regular, agreed contact. People who hear nothing for weeks return later and more reluctantly.
- Yes, as agreed3 pts
- Occasional1 pt
- None0 pts
Contact Frequency Agreed With Worker*
- Yes3 pts
- No0 pts
Worker Preference Respected*
- Yes3 pts
- No0 pts
Occupational Health Involved*
- Yes3 pts
- Not needed3 pts
- No0 pts
Referral ID
Links to HLT-013 Referral ID
Support Referral Made
Support Referral ID
Links to HLT-026 Referral ID
Modified Duty Plan ID
Links to HLT-018 Plan ID
Restriction Record ID
Links to HLT-017 Record ID
Prevention
13 fieldsRoot Cause Investigated
- Yes3 pts
- Not applicable3 pts
- No0 pts
RCA ID
Links to FDN-013 RCA ID
Others At Similar Risk*
One case usually means several people doing the same task under the same conditions.
- No3 pts
- Yes0 pts
Extent Of Condition ID
Links to FDN-018 Review ID
Risk Assessment Reviewed*
- Yes3 pts
- Partly1 pt
- No0 pts
Action Required*
Raise the action record, then enter its reference here.
- No2 pts
- Yes0 pts
Priority
- High0 pts
- Medium1 pt
- Low3 pts
CAPA ID
Format CAPA-2026-00000.
Links to FDN-014 CAPA ID
Action Owner
Case Manager*
Signature*
Occupational Health*
Second Signature*
HLT-016 · record IDs look like HCASE-2026-000 · Links Worker, Case
Open in KnowellaRun it with agents
From a document you fill in to a programme that runs itself
The record itself is simple to fill in correctly. What fails is the boundary around it: content that drifts into fields never meant to hold it, and a prevention loop that only fires for the cases that look serious.
Holds the case thread across referral, plan, restriction and closure, and flags a case that has stayed open past its expected duration without a linked record.
Watches for free-text entries in non-confidential fields that resemble clinical content, and raises it before the case is shared beyond occupational health.
Picks up a case flagged others at similar risk and feeds it into the relevant risk assessment review, so it becomes a control decision, not a closed file.
Checks that access restricted to occupational health matches actual system permissions, rather than trusting the field answer alone.
This template lives in KnowHealth — employee wellbeing. Exposure monitoring, health surveillance, case management and return to work.
Meet KnowHealth→Glossary
Occupational Health Case Record definitions and key terms
- Special category data
- Health information, which under UK and EU data protection law needs a specific processing condition beyond the general lawful basis for ordinary personal data.
- Function statement
- A description of what a worker can and cannot currently do, stated without reference to diagnosis, prognosis or treatment.
- Case thread
- The chain of records, case, referral, plan, restriction, closure, carrying the same case reference so the history can be traced without any one record holding everything.
- Root cause investigation
- A structured examination of why a work-related case occurred, used here to decide whether other workers face the same exposure.
- Appropriate policy document
- The document required under the DPA 2018 setting out how an organisation complies with data protection principles when processing this data.
FAQ
Frequently asked questions about occupational health case record
Does the case record need the worker's consent to exist?+
No. Occupational health can hold health data for occupational medicine purposes under UK GDPR art.9(2)(h) without consent. Consent here governs a narrower, later decision: whether the fitness outcome is shared with the employer. Conflating the two leads teams to think a case needs a signature it does not.
What should a line manager actually see from this record?+
The effect on work and any restriction, nothing more. If the record is well written that is also all there is to see, because the diagnosis was never entered. A manager asking for more should be told no by policy, not case by case.
Should a non-work-related condition go through the same prevention section as a work-related injury?+
The root cause and similar-risk questions matter less there, but skipping the section entirely for work-related ill health because it looks less dramatic than an injury is the actual failure mode, not skipping it for a non-work case.
What happens if the worker withdraws consent partway through the case?+
The employer stops receiving the fitness outcome from that point; the case stays with occupational health. Withdrawal does not close the case or remove the data, and the record should show the withdrawal date rather than just flipping the answer.
Who should be named as case manager?+
Someone in occupational health with authority to coordinate the referral, plan and restriction records under this case. Naming a line manager as case manager collapses the confidentiality boundary the design depends on.
How does this record connect to a return to work programme?+
It is the case index the programme's other instruments hang off. The programme plan sets the trigger and roles; this record proves a specific case was opened, tracked and linked to what followed.
Keep going
Related templates and programmes
Industries this is written for
Programmes this belongs to
Used together in Return to Work
Work Restriction Record
Records what a worker can and cannot do while recovering, and for how long
Modified Duty Plan
Sets out the temporary duties a recovering worker will perform
Case Progress Review
Reviews how a health case is progressing against its expected timeline
Case Closure Record
Closes a health case, recording the outcome and any lasting restrictions
Claim Support Record
Records the information provided to support a workers compensation claim
Absence Trend Review
Reviews absence patterns by area, shift and cause category to find where work is making people ill
Written and reviewed by
Siddarth Singh
Founder & Chief Executive Officer, Knowella
Certified Safety Professional and industrial and systems engineer with more than a decade inside food supply chain, freight and manufacturing operations. This page was written against the current text of the standards it cites, not against secondary summaries of them.
- Certified Safety Professional (CSP), Board of Certified Safety Professionals
- MBA, University of Chicago Booth School of Business
- MS and BS, The Ohio State University, Industrial and Systems Engineering
- Six Sigma Black Belt
Sources and last review. Reviewed 16 August 2026 against:
- UK GDPR article 9, processing of special categories of personal data
- Data Protection Act 2018, Schedule 1, Part 1, paragraph 1
- ADA regulations 29 CFR 1630.14(c), confidentiality of medical information (US, for comparison)
- ISO 45001:2018 clauses 5.4 and 6.1.2.1
This page is general guidance, not legal advice. Confirm requirements with your jurisdiction’s regulator.