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

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.
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).
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.
Protect the confidentiality and privacy of all forms of patient/client documentation in compliance with legislative, regulatory, and employer requirements.
Access patient/client personal information only as required for the provision of care.
Transport and store patient/client information in a safe and secure manner.
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.


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]


  1. Adapted from College of Respiratory Therapists of Ontario. (2014). Responsibilities under Consent Legislation. Professional Practice Guideline. Available at:
  2. Adapted from College of Respiratory Therapists of Ontario. (2010). A Commitment to Ethical Practice. Available at:
  3. Merriam-Webster. (2016). Online Dictionary. Available at: