Medical Documentation Management FAQs
What is medical documentation?
Medical documentation is any written information a department has regarding an employee’s ability to work that is related to a health condition. Typically the document is provided and signed by the treating health practitioner; however, an employee’s written disclosure also serves as a medical document.
Documentation may be specific to an employee’s personal health condition or an employee’s need for absence for an ill or injured family member. Examples of medical documentation include and are not limited to:
- Documentation supporting an accommodation request;
- FMLA health certification forms;
- Release to work documents;
- Worker’s Compensation documentation;
- Any other documentation requesting short term restrictions, work absence, or any other health information; and
- In rare instances, performance evaluations or disciplinary records erroneously containing reference to health concerns
Is medical information confidential?
Whether the information is contained in a document or has been learned by verbal disclosure, The Americans with Disabilities Act and the Family Medical Leave Act considers information of an applicant’s or employee’s medical history, medical condition, leave and accommodation confidential.
First aid and safety personnel should be informed, when appropriate, if the health condition might require emergency treatment; or if any specific procedures are needed in the case of fire or other emergency requiring evacuation.
Medical documentation must be held in a separate medical file (considered a sub file of the personnel file) and is not to be held in the personnel file. References to health conditions in performance evaluations or other employee performance coaching, etc., should be removed from the performance evaluation and placed in the medical file.
Who has access to medical documentation?
Medical documentation is confidential. The HR Representative is responsible to receive (whenever possible) and reviews medical documentation. The HR Representative should forward all medical documentation to FSDS for assistance in complex interactive accommodation processes and when working with FSDS in leave management. The HR Representative will share necessary limitations, absence and accommodation information with manager(s) and supervisor(s). To reduce potential perceived bias or conflict, supervisors should not be informed of diagnoses by other members of management.
I’ve received medical documentation. What should I do with it?
Medical documentations should be received by the HR Representative but if a supervisor does receive it, the supervisor is to forward the medical documentation to the employee’s HR Representative. HR Representatives are to address the information contained in the documentation, i.e., absence needs, limitations, etc., following the leave and interactive process procedures.
How is medical documentation to be stored?
Medical documentation is to be stored in a secure and separate file than the personnel file. The file is considered a sub file of the personnel file and access is limited to HR Representatives and employers needing access in the course of assisting the employee in leave, performance and disability matters.
What should be done when an employee shares medical information in the performance evaluation document?
There are two options available when an employee writes health information on the performance evaluation:
- Remove the entire performance evaluation from the personnel file and transfer it to the medical file. Put a note in the personnel file as a reminder that the evaluation is located in the medical file.
- Transfer the page that references the health information into the medical file and attach a note to the evaluation that the page is in the medical file.
What is done with the medical file when an employee moves to another University position?
The medical file will transfer with the employee. However, documentation of accommodations, including leave of absence covered under the ADA, are to be removed from the file and transferred to FSDS. If the employee needs an accommodation in the new job, he/she must make a request to the new department.
What is done with the medical file when an employee leaves The University of Iowa?
Medical documentation of accommodations, including leave of absence, covered under the ADA should be forwarded to FSDS at the time of the employee’s departure. The balance of the medical file is to be maintained by the employer for a period including: current year plus three more years. Following this period, they can be confidentially destroyed.
- The University of Iowa Operations Manual, Division III, Chapter 7: Access to Personnel Files
- 42 USC Sec. 12112(d)(3)(B)
- 29 CFR Parts 1630, 1602
- EEOC Policy guidance On Executive Order 13164: Establishing Procedures to Facility The Provision Of Reasonable Accommodation. Question 20, (10/20/2000)
- EEOC ADA Enforcement Guidance: Pre-employment Disability-Related Questions and Medical Examinations, (10/10/1995).
Page last updated December 2012