x The effects of occupational exposures often occur after a
long latent interval following exposure
x Healthcare professionals receive scant instruction on how
to identify the etiology of diseases caused by occupational
and noninfectious environmental exposures4
This underestimation affects patients, payers, and researchers. It can lead to missed opportunities for prevention; divert
costs that should be paid by workers’ compensation insurance
to health insurance companies, Medicare, Medicaid, Social
Security, or the patient; and hamper research that is based on
Timely recognition of work-related injuries and illnesses requires that work history be captured in every patient’s record.
Timely recognition can lead to reductions in hazardous exposures to individual patients, improve the likelihood that resulting costs are paid for by the employer responsible for the workplace exposures, and can produce robust databases useful for
recognizing, managing, and preventing work-related injuries
The national effort to promote electronic health records makes
this an important time to advance the capture of standard occupational data elements that will enhance occupational disease
and injury recognition and prevention from three perspectives:
prevention and treatment of individual cases of occupational injury or disease; identification of occupational disease outbreaks
or clusters; and surveillance, epidemiology, and research of occupational injuries or diseases.
Promoting Treatment and Prevention
Knowing a patient’s occupation may help identify the cause of
illness. For example, a clinician might be puzzled by a previously healthy, nonsmoking adult with new-onset asthma, until
learning that she is employed as a home health aide and recently began using a disinfectant for her job known to cause asthma.
Diagnosing an occupational etiology will improve the chances
of the patient’s recovery if the exposure precipitating the illness
can be reduced or eliminated.
Using this example, the clinician may be able to help the patient convince her employer to switch to another disinfectant.
Avoiding the asthma-inducing disinfectant will not only improve the patient’s condition, but it may also prevent additional
cases of asthma among her coworkers and even patients. 6 Furthermore, identifying and stopping the cause of the patient’s
asthma precludes prescribing medication to control symptoms
that would likely persist with continuous exposure.
Recognizing and documenting an occupational cause for a patient’s illness can guide the treatment plan and allow the patient
to apply for workers’ compensation to cover medical costs and
some lost wages. Obtaining workers’ compensation benefits for
occupational diseases can be difficult, and documentation in
the medical record that the worker’s illness was work-related is
vital to winning a workers’ compensation case.
In addition to recognizing how current health conditions re-
Current Classifications for Industry and
NO FORMAL DATA standards exist for collecting occupational history data in medical records; however, fields for
usual (longest-held) industry and occupation (I&O) of employment are present on death certificates and in cancer
registries. 5 Additionally, I&O data are collected in many federal surveys, including the American Community Survey and
the National Health Interview Survey.
The Office of Management and Budget and the US Census
Bureau employ standard coding systems to classify industry
and occupation data collected in narrative format into reasonable numbers of categories. The sidebar on page 36 offers a sample of Census Bureau classifications.
late to work, knowing a patient’s occupation offers an opportunity for education to prevent common work-related problems
such as hearing loss or back pain before they occur.
For example, up to 24 percent of hearing loss cases could be
prevented if workers were never exposed to workplace noise
levels above recommended levels. 7, 8 Many industries, including
farming, manufacturing, and construction, expose workers to
frequent and excessive noise levels. The proportion of hearing
loss cases attributable to occupational noise exposure is especially high in the railroad and mining industries.
Workers in these industries should be counseled on how to
avoid excessive noise exposure and the need for consistent use
of hearing protection (e.g., earplugs) if avoidance is impossible. 9
Further, they should also undergo periodic audiometry to monitor for hearing loss.
The main barriers preventing healthcare providers from taking occupational histories are the perceptions of a lack of time,
lack of awareness, and lack of skills to fully investigate how a disease is related to work. However, including occupational data
in the standard medical record may prompt busy clinicians to
consider links between patients’ jobs and their health and the
need for referral to an occupational health specialist.
Identifying Occupational Outbreaks or Clusters
Recognizing an outbreak or cluster of a new or unusual disease
among patients with the same or similar occupations is important to identifying emerging occupational diseases. The following example illustrates the process. 10
In February 1993 a 34-year-old man who worked in a textile
plant in Rhode Island suddenly developed a headache, chest
pain, and shortness of breath three hours into his work shift. His
symptoms disappeared spontaneously, but a few months later
he began to experience work-related shortness of breath that resolved shortly after the end of each shift.
After collecting this work history, a pulmonologist suspected
an occupational cause, removed the patient from his job, and
prescribed prednisone. Two months after leaving work, the pa-