As per the American Academy of Allergy, Asthma and Immunology, occupational asthma has become the most common lung disease related to job in developed countries. Though the exact number of newly diagnosed occupational asthma patients is not known, it is estimated that up to 15% of asthma cases may be work-related. It is possible to reduce the morbidity of the condition with early diagnosis. However, labeling an asthma case as being occupationally-induced is a matter of clinical judgment. Identifying the specific reason for occupational asthma is much more difficult than identifying an asthma-work relationship. Accurate and comprehensive clinical documentation via medical transcription is essential to ensure appropriate care for patients with occupational asthma.
Irritants in high doses (such as hydrochloric acid, sulfur dioxide or ammonia) can induce occupational asthma. Prolonged exposure to fumes, gases, dust or other potentially harmful substances while on the job can make patients consume high doses of irritants inadvertently. Allergies are another reason for occupational asthma. People having personal/family history of allergies are more likely to develop occupational asthma to certain substances (for example, flour, animals and latex). Certain personal habits such as smoking also increase the risk for developing occupational asthma. Apart from history, physical examination and diagnosis tests are required to establish the diagnosis of this condition. The following documentation is needed.
Medical History Report
This includes the personal details of the patients which helps the physicians to identify occupational asthma. The major details in this report are:
- Characteristic symptoms (wheezing, coughing, chest tightness and shortness of breath
- Past respiratory history (prior diagnosis of asthma, allergies, chest colds, eczema, hay fever, rhinitis, respiratory symptoms upon exertion, bronchitis, sinusitis, exposure to minor irritants, or exposure to cold air
- Review of systems (history of other diseases having symptoms that could mimic or precipitate asthma)
- Family history (asthma, atopy)
- Smoking history (average packs of cigarettes per day along with years smoked)
- List of current medications
- Home, hobby, and environmental exposure history to exclude other causal or contributing factors
Occupational History Report
This includes details related to the patient’s job, which helps physicians understand the specific causes of occupational asthma. The report would comprise the following information.
- Patient’s work-related tasks, exposures and related processes (both past and present)
- Effects of workplace exposures on respiratory symptoms with temporal associations. The symptom changes on weekend and/or vacation.
You may require worksite evaluation by an appropriate healthcare provider or industrial hygienist if the data for characterizing exposures is not adequate for correct diagnosis.
Physical Examination Report
Physicians can take up physical examination to either rule out or confirm the possibility of occupational asthma after going through the personal history and occupational history. There are different types of physical examinations such as:
- Examination of head for rhinitis, nasal polyps, conjunctivitis, and sinusitis
- Chest percussion and auscultation
- Cardiovascular exam to find out if any cardiogenic explanation for respiratory symptoms
- Skin exam for atopic dermatitis
The examination procedure and their results should be documented very clearly on physical examination report so that the physicians can confirm the possibility of occupational asthma.
Once the possibility is confirmed, diagnostic tests (for example, spirometry studies) can be conducted to finally establish the diagnosis. The procedures of the test, how frequently the test was conducted, test results and other details are documented on the laboratory reports.
In short, comprehensive and accurate clinical documentation is required to have correct and quick diagnosis of occupational asthma and start treatment as early as possible. Though electronic health records (EHRs) eases the documentation tasks and improves accessibility with pre-filled templates, copy-paste errors and limitations to narrative description still undermine the quality of documentation. An integrated approach involving both EHR and medical transcription service can be an effective solution in which physician recordings are transcribed, reviewed and populated into appropriate EHR fields via the latest transcription technology.