STANDARD 7.

Documentation & Information Management

Respiratory Therapists (RTs) must maintain complete, clear, timely , objective, and accurate documentation to support the continuity, quality, and safety of patient/client care.

Performance Requirements

RTs:

9

Document all patient/client contacts in a timely manner in the patient/client health record in the form and manner required by both the regulatory body and the employer.

9

Make appropriately detailed, accurate, legible, and clear entries in the patient/client health record (e.g., initial assessments, informed consent, status, interventions and responses, and follow-up/discharge plans).

9

Include the date, time, and their identifiable signature (e.g., hand-written, electronic) with protected professional title/professional designation on all documentation in the patient/client health record.

9

Protect the confidentiality and privacy of all forms of patient/client documentation in compliance with legislative, regulatory, and employer requirements.

9

Access patient/client personal information only as required for the provision of care.

9

Transport and store patient/client information in a safe and secure manner.

9

Comply with legislative, regulatory, and employer requirements related to record retention and disposal.

Patient / Client Expected Outcome

Patients/clients can expect that RTs keep complete, clear, timely, objective, and accurate records of the care provided and that privacy/confidentiality is protected.

RELATED RESOURCES

College of Respiratory Therapists of Ontario. (2013). Orders for Medical Care Professional Practice Guideline. Available at http://www.crto.on.ca/pdf/ppg/ordersmc.pdf
College of Respiratory Therapists of Ontario. (2014). Delegation of Controlled Acts Professional Practice Guideline. Available at http://www.crto.on.ca/pdf/ppg/delegation.pdf
College of Respiratory Therapists of Ontario. (2014). Interpretation of Authorized Acts Professional Practice Guideline. Available at http://www.crto.on.ca/pdf/ppg/interpretation.pdf
College of Respiratory Therapists of Ontario. (2014). Responsibilities under Consent Legislation. Professional Practice Guideline. Available at: http://www.crto.on.ca/pdf/PPG/UnderConsent.pdf
College of Respiratory Therapists of Ontario. (2015). Respiratory Therapists Providing Education. Professional Practice Guideline. Available at: http://www.crto.on.ca/pdf/PPG/MembersAsEducators.pdf
College of Respiratory Therapists of Ontario. (2015). Documentation Professional Practice Guideline. Available at: http://www.crto.on.ca/pdf/ppg/documentation.pdf
College of Respiratory Therapists of Ontario et al. (2013). Pause Before You Post: Social Media Awareness for Regulated Healthcare Professionals E-learning Module. Available at http://www.crto.on.ca/members/professional-development/e-learning/
National Alliance of Respiratory Therapy Regulatory Bodies. (2016). National Competency Framework for the Profession of Respiratory Therapy. Part 1. National Standards for Entry-to-Practice. Available at: http://www.csrt.com/2016-national-competency-framework/

GLOSSARY

Appropriately refers to in accordance with ethical, legal, technical and/or clinical requirements of professional practice.

Informed consent means that the information relating to the treatment must be received and understood by the patient/client.[1]

Patient/client refers to individuals and their families requiring care or services. This may also include his/her substitute decision-maker or guardian.[2]

Timely refers to “happening at the correct or most useful time: not happening too late.”[3]

Related Standards

$

S3. Communication

$

S10. Patient/Client Assessment & Therapeutic Procedures

$

S11. Privacy/Confidentiality

$

S13. Professional Responsibilities

FOOTNOTES

Adapted from College of Respiratory Therapists of Ontario. (2014). Responsibilities under Consent Legislation. Professional Practice Guideline. Available at: http://www.crto.on.ca/pdf/PPG/UnderConsent.pdf
Adapted from College of Respiratory Therapists of Ontario. (2010). A Commitment to Ethical Practice. Available at: http://www.crto.on.ca/pdf/Ethics.pdf
Merriam-Webster. (2016). Online Dictionary. Available at: http://www.merriam-webster.com/dictionary/timely