Standard 7 - Documentation & Information Management

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:

• 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.
• Must be clear in their documentation what care they provided themselves and what care was provided by others.
• 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.

1. 1. Protect the confidentiality and privacy of all forms of patient/client documentation in compliance with legislative, regulatory, and employer requirements.
   2. 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.

 Related Standards

• Communication
• Patient/Client Assessment & Therapeutic Procedures
• Privacy/ Confidentiality
• Professional Responsibilities

 Related Resources

• College of Respiratory Therapists of Ontario. (2021). Respiratory Therapists Providing Education. Professional Practice Guideline. Available at: https://education.crto.on.ca.
• 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: https://nartrb.ca/download/ncf-part-i-entry-to-practice-2016.
• National Alliance of Respiratory Therapy Regulatory Bodies. (2024). National Competency Framework. Available at: https://nartrb.ca/national-competency-profileframework.
• Nova Scotia Regulator of Respiratory Therapy. (2020). NSRRT Documentation Guideline. Available at: https://nsrrt.ca/images/202002_Documentation_Guideline.pdf
• Nova Scotia Regulator of Respiratory Therapy. (2017). NSRRT Social Media Guideline. Available at: https://nsrrt.ca/images/NSRRT_Social_Media_Guideline.pdf
• Nova Scotia Regulator of Respiratory Therapy. (2024). NSRRT Transfer of Accountability Guideline. Available at: https://nsrrt.ca/images/APPROVED_Transfer_of_Accountability_Guideline_20240131.pdf

 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. Consent may be implied or expressed. Implied consent is determined by the actions of the patient/client. Implied consent may be inferred when performing a procedure with minimal risk that the patient/client has consented to previously and acts in a manner that implies their consent. Expressed consent is more official and may be written or oral.^[1]

Patient/client refers to “individual, group, community or population who is the recipient of respiratory therapy services and, where the context requires, includes a substitute decision-maker for the recipient of respiratory therapy services”.^[2]

Timely refers to actions, interventions, or responses that are carried out within an appropriate or necessary timeframe to achieve the best possible outcome.”^[3]

 ^[1] College of Respiratory Therapists of Ontario. (2022). Responsibilities under Consent Legislation. Professional Practice Guideline. Available at:  https://responsibilities.crto.on.ca/

^[2] Nova Scotia Government. Regulated Health Professions Act (2023). Available at:  https://nslegislature.ca/sites/default/files/legc/statutes/regulated%20health%20professions.pdf

^[3] Open AI. (2025). ChatGPT (May 14 version) [Large language model]. https://chatgpt.com