Occupational health professionals play a balancing act protecting workers while supporting employers in meeting regulatory requirements. But even experienced providers can inadvertently stumble into legal trouble through the way they document visits, exams, and employer communications. Unlike general medical records, occupational medicine documentation operates within a narrow channel of legal permissions. The consequences for drifting outside that lane can be steep: EEOC investigations, GINA and ADA violations, and six-figure settlements.
This article explores real-world examples of how poor documentation has triggered legal action, and explains how occupational health professionals can protect themselves and their organizations through better forms, workflows, and communication practices. It also clarifies when more traditional clinical elements like family history can be safely included—and when they become a violation.
What Makes Occupational Health Documentation Different?
Occupational medicine documentation exists at the intersection of employment law, disability rights, and clinical care. In this environment, the purpose of the visit matters as much as the medical content. A preplacement exam, a return-to-work visit, and a wellness screening might look similar on paper, but each follows different rules for what can be asked, recorded, and shared.
The Americans with Disabilities Act (ADA) governs medical exams and inquiries related to employment. It limits what can be asked and when. Post-offer exams can include some job-related medical history, but cannot collect information unrelated to the essential job functions. The Genetic Information Nondiscrimination Act (GINA) goes even further by prohibiting the collection of family medical history in employment-related exams.
When clinicians approach occupational health visits with a primary care mindset—using standard intake forms or documenting diagnoses and treatments in employer communications—they risk violating these laws, even with the best of intentions.
Real Cases, Real Consequences
In 2013, Fabricut, Inc. became the first company sued by the EEOC under GINA. The company rescinded a job offer after the applicant’s post-offer medical exam included questions about family medical history and led to a referral to a specialist. The EEOC stated:
“Employers need to be aware that GINA prohibits requesting family medical history,” said David Lopez, EEOC General Counsel. (EEOC.gov)
Fabricut paid $50,000 to settle the case and agreed to revise its procedures.
In a more recent example, Dollar General paid $1 million to resolve an EEOC lawsuit alleging systemic violations of both GINA and the ADA. According to the EEOC, applicants were required to disclose:
“past and present medical conditions of family members such as cancer, diabetes, and heart disease.” (HCAMag)
Moreover, the medical examiners provided detailed diagnoses and medical information to hiring managers—a direct violation of ADA confidentiality rules. The EEOC emphasized that job offers cannot be revoked based on generalized risk or family medical history.
These cases highlight the hidden risks lurking in common documentation practices, particularly when using preprinted forms or templates borrowed from general practice.
When Asking About Family History Is a Problem—and When It Isn’t
Family history is a cornerstone of preventive medicine, but it’s off-limits in most employment-related contexts. Under GINA, providers cannot request, require, or purchase genetic information, which includes family medical history, during any stage of the employment process. (EveryCRSReport.com)
However, there are exceptions:
- Wellness programs: If part of a voluntary health risk assessment (HRA), with appropriate consent and safeguards, family history can be collected.
- Health fairs: Screenings offered to employees as voluntary services, not tied to hiring or return-to-work, may include family history as long as information is not shared individually with the employer.
- Aggregate data reporting: Clinics may share group-level, de-identified wellness trends with employers to help guide benefit design—but never individual data.
So everything we’ve been advocating to break down silos, integrating interventions for general health risks and effects on work related injuries, absences, loss of productivity, Total Worker Health® initiatives is all still relevant.
To remain compliant, occupational health programs must clearly segregate employment-related records from wellness or preventive care documentation.
The Limits of What Can Be Shared with Employers
Under the ADA, employers are only entitled to know whether an individual can perform the essential functions of the job, with or without restrictions. They are not entitled to know the underlying diagnosis, treatment plan, medications, or unrelated findings. (ADA.gov)
Yet it’s common to find medical records in occupational settings that include statements like:
“Employee has hypertension, controlled on lisinopril, and is fit for duty with no restrictions.”
This kind of documentation, if shared with an employer, violates ADA confidentiality rules. It also places the clinic and provider at risk.
The correct approach? Keep clinical detail in the internal chart. Provide employers with a simple, job-focused summary:
“Medically cleared to perform all essential job functions without restrictions.”
or
“Cleared for work with the following limitations: no lifting over 25 lbs, avoid climbing ladders.”
Templates and Workflows That Prevent Violations
To document occupational visits properly, providers must use templates designed for the specific type of service. General wellness templates, or primary care forms, can introduce prohibited fields like family history, review of systems, or open-ended diagnoses.
Instead, post-offer and return-to-work exams should include:
- A checkbox or statement confirming review of the job description
- Functional exam findings tied to job demands (e.g., lifting, squatting, standing)
- A job-specific medical history section (e.g., history of back injuries for a lifting job)
- Documentation of work status, restrictions, and anticipated follow-up if needed
Drug screen workflows must also be limited. In non-DOT settings, results should be communicated to the employer as “negative” or “non-negative/referred to MRO” without further interpretation. (WorkSaver Systems)
Building a Legally Defensible Occmed Program
Clinics can protect themselves by training providers on the distinctions between clinical and occupational records, adopting compliant templates, and auditing documentation for risk. Policies should reinforce that family history, diagnosis disclosure, and general wellness content have no place in employment-based exams.
NAOHP offers a Documentation & Compliance Toolkit designed specifically for occupational health. It includes editable templates, safe harbor language, video training, and checklists for clinics that want to get ahead of these risks.
Final Thoughts
The risks in occupational health documentation are subtle but real. By understanding the legal frameworks of GINA, ADA, and HIPAA—and adjusting your workflows accordingly—you can protect your practice, your clients, and your patients.
For more guidance, NAOHP members can access free resources in the member library. Non-members can purchase the full Toolkit or join to receive discounted access.
Don’t wait for an EEOC investigation to change your forms.
👉👉 Explore the NAOHP Documentation & Compliance Toolkit:
