Occupational medical records: content, custody and access

An occupational medical record is health documentation connecting a person’s health with their tasks, exposures and work history. It forms part of health surveillance. It is not the same as the fitness certificate received by the employer or the administrative human resources file.

In brief

Occupational medical records combine health information and occupational exposure to support health surveillance. They require custody, justified access and retention under applicable rules. Employers receive necessary preventive conclusions, without general access to diagnoses or clinical documentation.

Contents
  1. What information it connects
  2. Medical records and personnel files
  3. Who may access it
  4. Retention and continuity
  5. Access rights and corrections
  6. Hypothetical example: changing roles
  7. Related concepts
  8. References

A–Z dictionary →

What information it connects

Article 37.3 of Spain’s Prevention Services Regulations covers medical history, examination and studies linked to risks. It adds the job description, time in the role, identified risks and measures adopted, as well as previous jobs where that information is available.

This connection enables a result to be interpreted within its occupational context. A list of tests without work information loses some of its value. Updates should distinguish what is known, what the person reports and information still outstanding.

Medical records and personnel files

The record must remain separate from administrative documents such as contracts, leave or equipment allocation. It is also distinct from the conclusions report that enables the employer to adopt preventive measures.

A useful organisational practice is to define what information the employer supplies to health professionals and what conclusions it receives. Creating a folder labelled confidential is not enough if it retains general human resources permissions. Separation must exist in access, functions and communication routes.

Who may access it

The Spanish Data Protection Agency, AEPD, emphasises that being a health professional does not permit access to any medical record: access must be necessary for that person’s work. Administrative staff may access only the data necessary for their duties.

Assign permissions according to need and log access appropriately. Manage professionals joining, providing cover and leaving. When technology is involved, clarify responsibilities and security measures. Avoid shared accounts that prevent identification of who viewed or changed an entry.

Retention and continuity

Law 41/2002 regulates retention, security and orderly documentation. Its general minimum must not become an automatic deletion rule: longer periods may apply under regional rules, specific risks or other legitimate purposes.

The end of employment does not by itself determine deletion either. Define a justified retention schedule. When the health service changes, organise continuity and document handling according to responsibilities and lawful bases, without indiscriminately handing records to the client employer.

Access rights and corrections

The person may request access to and a copy of their record under health and data protection legislation, subject to legal limits concerning, among other matters, third parties and subjective annotations. The AEPD identifies the data controller as the recipient of the request.

Provide an identifiable, secure channel. If incorrect data are found, handling must preserve integrity and traceability; correction does not mean silently rewriting the past. Requests require assessment according to their nature and applicable legislation.

Hypothetical example: changing roles

A person moves from an administrative task to one involving different exposure. The employer communicates the duties and updated assessment to the health service. The service incorporates the new information and determines the appropriate action.

Human resources receives the necessary preventive conclusions without adding clinical results to its personnel file. If the health provider later changes, continuity arrangements are prepared. The exposure history remains understandable without improperly widening access to medical information.

References

  1. BOE: Prevention Services Regulations, Article 37.3. Official source
  2. BOE: Law 41/2002 on clinical documentation. Official source
  3. AEPD: professionals’ access to health data. Official source
  4. AEPD: requesting a copy of a medical record. Official source

Editorial information

Publication date: 19 October 2026.

Editorial responsibility: Sabentis Editorial Team.

Author: Pablo RodríguezLinkedIn

Executive Vice President of the ORP International Foundation and Chief Financial Officer of Sabentis.

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