{"id":29,"date":"2020-06-12T16:42:29","date_gmt":"2020-06-12T20:42:29","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/documentation\/?post_type=chapter&#038;p=29"},"modified":"2026-06-17T14:19:36","modified_gmt":"2026-06-17T18:19:36","slug":"principles-of-documentation","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/chapter\/principles-of-documentation\/","title":{"raw":"Principles of Documentation","rendered":"Principles of Documentation"},"content":{"raw":"As a nurse, you are legally obligated to complete documentation. You should refer to the <strong>legislative<\/strong> and <strong>regulatory requirements<\/strong> for documentation in the province or territory that you work. In Ontario, you should first <strong>closely review<\/strong> the Documentation practice standard found at: <a href=\"https:\/\/cno.org\/Assets\/CNO\/Documents\/Standard-and-Learning\/Practice-Standards\/41001_documentation.pdf\" target=\"_blank\" rel=\"noopener\">CNO Documentation<\/a>\r\n\r\nAs per the CNO (2025), there are three documentation principles:\r\n<ul>\r\n \t<li>Communication.<\/li>\r\n \t<li>Documentation requirements.<\/li>\r\n \t<li>Information security.<\/li>\r\n<\/ul>\r\nThere are several indicators that facilitate nurses\u2019 application of the three documentation principles to their practice. <strong>Table 3, 4, and 5<\/strong> present common questions related to the indicators for the above three principles.\r\n\r\n<strong>Table 3<\/strong> focuses on communication: the requirement that \u201cEffective communication is a foundational documentation accountability that promotes safe and quality nursing care. Nurses must apply their knowledge, skill and judgment when documenting, ensuring their documentation is a clear, complete and accurate representation of the client\u2019s health status including the nursing care provided and any significant interactions.\u201d (CNO, 2025, p. 6).\r\n\r\n&nbsp;\r\n\r\n<strong>Table 3:<\/strong> Communication\r\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%\" border=\"0\">\r\n<tbody>\r\n<tr>\r\n<td class=\"shaded\" style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\"><strong>Questions<\/strong><\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\"><strong>Considerations<\/strong><\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\"><strong>Additional EHR Considerations<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\u201cWhat does it mean to document both <strong>objective<\/strong> and <strong>subjective<\/strong> data?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">In addition to providing care, you must document using a combination of subjective (what the client says) and objective (what you observe) data.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">Comprehensive documentation of subjective and objective data will require using both structured and unstructured data elements.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\u201cHow do I ensure that my documentation is a <strong>complete record<\/strong> of the nursing process?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">A complete record includes of all phases of the nursing process: assessment (e.g., subjective and objective data); plan of care and interventions (e.g., hygiene care, assistance with mobility, treatments such as turning the client and medications, health teaching); and evaluation of the care you provide (e.g., how did the client respond?). In addition, a complete record includes all relevant communication and attempts at communication with the healthcare team including the client and family. CNO (2025) indicates that documentation of communication should include the communication mode, the person's name and designated title (when applicable), and the discussion outcome.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">No additional considerations.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\u201cWhat do I need to consider so that my documentation is <strong>clear<\/strong>, <strong>relevant<\/strong>, <strong>individualized<\/strong> to the client, and with <strong>minimal duplication<\/strong>?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">Your documentation must be precise and coherent so others can understand. Vague and obscure documentations can lead to misinterpretation.<\/p>\r\n<p class=\"no-indent\">Documentation should be specific and individualized to each client.<\/p>\r\n<p class=\"no-indent\">Your documentation should balance being comprehensive and concise. This will become easier with practice. Try to include all relevant information and omit unimportant information. For example, a client may tell you a story that is irrelevant to their reasons for seeking care or your assessment; do not include this. Try to be succinct and avoid documenting the same thing twice.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">Structured data should be entered according to the structures included in the EHR. For example, the EHR may require a specific format to enter the value for the field \u201cblood pressure.\u201d<\/p>\r\n<p class=\"no-indent\">Unstructured data should be documented using the same best practices as those used for paper documentation.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\u201cHow do I ensure that my documentation is <strong>free from discrimination<\/strong>?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">You are responsible for adhering to the <a href=\"https:\/\/www.ontario.ca\/laws\/statute\/90h19?search=ontario+human+rights+code\" target=\"_blank\" rel=\"noopener\">Ontario Human Rights Code<\/a> Ontario Human Rights Code when documenting. This means that you should be respectful of a client's identity and how you refer to it in your entries (e.g., race, ethnic origin, citizenship, sex, sexual orientation, gender identity, gender expression). As an example, you should be respectful of how a client self identifies (e.g., pronoun usage).<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">No additional considerations.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n&nbsp;\r\n\r\n&nbsp;\r\n\r\n<strong>Table 4<\/strong> focuses on documentation requirements: the requirement that documentation is \u201cconsistent, appropriate, and accurate ... [and] support accessibility, ensure continuity, and uphold legal as well as professional accountabilities\u201d (CNO, 2025, p. 8).\r\n\r\n&nbsp;\r\n\r\n<strong>Table 4:<\/strong> Documentation requirements\r\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%;height: 1029px\" border=\"0\">\r\n<tbody>\r\n<tr style=\"height: 30px\">\r\n<td class=\"shaded\" style=\"width: 33.3333%;height: 30px\">\r\n<p class=\"no-indent\"><strong>Indicator<\/strong><\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 33.3333%;height: 30px\">\r\n<p class=\"no-indent\"><strong>Consideration<\/strong><\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 33.3333%;height: 30px\">\r\n<p class=\"no-indent\"><strong>Additional EHR Considerations<\/strong><\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 125px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">\u201cHow do I record the <strong>date<\/strong> and <strong>time<\/strong> of my documentation?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">Use the 24-hour clock (also called military time; see <strong>Figure 1<\/strong>). Generally, the documentation date and time should reflect the time of your documentation entry as opposed to the time you provided the care. However, when documenting vital signs, medication administration, or other procedures, you should specifically note the time that the task was performed.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">EHRs capture your digital identity and time stamps of your activities.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 204px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 204px\">\r\n<p class=\"no-indent\">How do I ensure that a <strong>unique identifier<\/strong> is used to sign documentation entries?<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 204px\">\r\n<p class=\"no-indent\">First, note that \u201cregistered nurse\u201d and \u201cnurse\u201d are protected titles in Ontario, and you can only use them as a designation if you are registered with the CNO (2020). Your educational institution will discuss with you what designation you should use as a nursing student. You must provide your full legal name (printed), signature, and initials on a main sheet. Your name and designation must be consistent with your CNO registration and can only be in English or French. Typically, a signature is written in cursive (as opposed to printed) and is something that is unique to you, usually includes your first and last name or first initial and last name.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 204px\">\r\n<p class=\"no-indent\">EHRs provide ways of including your signature and designation electronically. They may require you to sign on and off digitally, include your digital identity, password, and time stamps of your activities, and limit or restrict access to certain functions for students.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 220px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 220px\">\r\n<p class=\"no-indent\">\u201cHow do I ensure that my documentation is <strong>timely<\/strong> and when do I indicate it as a <strong>late entry<\/strong>?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 220px\">\r\n<p class=\"no-indent\">You are expected to document promptly after an assessment or providing care. Do not wait until the end of your shift to document, and never document prior to providing care. Sometimes it may not be possible to document promptly because another client or nurse requires your assistance; in this case, document as quickly as you can and identify it as a \u201clate entry.\u201d You will still include the time that you are documenting, and in the first line include something like \u201cLate entry. Assessment and care provided at XX\u201d (and specify the time the care was provided). Each workplace should have policies and procedures concerning late entries; if not, you should advocate for them.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 220px\">\r\n<p class=\"no-indent\">Documentation date and time are captured by the EHR along with your digital identity and time stamps of your activities.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 61px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 61px\">\r\n<p class=\"no-indent\">\u201cWhat does it mean to document in a <strong>chronological order<\/strong>?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 61px\">\r\n<p class=\"no-indent\">Chronological order means that your documentation is arranged in order of time: from what happened first to what happened last.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 61px\">\r\n<p class=\"no-indent\">No additional considerations.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 125px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\u201cWhat should I consider in terms of ensuring my hand-written documentation is <strong>legible<\/strong> and completed in <strong>permanent ink<\/strong>?\u201d\r\n<p class=\"no-indent\"><\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">Your hand-written documentation must be legible, meaning that it can be read and understood by others: if your cursive writing is poor, consider printing. Permanent ink is specified because you are generally not permitted to use pencil to document. Black ink is usually best because it yields the best photocopies, but red and blue ink is required for certain vital sign graphs.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">One advantage of EHRs is the avoidance of legibility issues related to hand-written documentation.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 93px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 93px\">\r\n<p class=\"no-indent\">\u201c<strong>Who<\/strong> should complete the documentation note?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 93px\">\r\n<p class=\"no-indent\">Only document your own observations and actions. Do not document the observations and actions of other healthcare providers except in situations where you are a designated recorder, such as during code situations. Co-signing of documentation notes is not permitted.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 93px\">\r\n<p class=\"no-indent\">No additional considerations.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr style=\"height: 125px\">\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">\u201cHow do I <strong>correct<\/strong> a documentation note when an <strong>error<\/strong> is made while documenting?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">It is vital that any error in a written documentation note remains visible. Do not scribble over the error or use correction fluid. Unless there is a specific organizational policy, draw a single line through the error and initial it. Some organizations have policies such as writing the word \u201cerror\u201d and including the date\/time and your signature.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\r\n<p class=\"no-indent\">In an EHR, you can add an additional note referencing the error. It will capture this information along with your digital identity and time stamps of your activities.<\/p>\r\n<p class=\"no-indent\">Some EHRs have specific functions to address errors in documentation. You will become familiar with the conventions used in each.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n&nbsp;\r\n\r\n&nbsp;\r\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%;height: 126px\" border=\"0\">\r\n<tbody>\r\n<tr style=\"height: 14px\">\r\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\"><strong>24-hour clock<\/strong><\/p>\r\n<\/th>\r\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\"><strong>Standard time<\/strong><\/p>\r\n<\/th>\r\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\"><strong>24-hour clock<\/strong><\/p>\r\n<\/th>\r\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\"><strong>Standard time<\/strong><\/p>\r\n<\/th>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\"><strong>24-hour clock<\/strong><\/p>\r\n<\/td>\r\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\"><strong>Standard time<\/strong><\/p>\r\n<\/th>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0000<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">midnight<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0800<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">8 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1600<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">\u00a04 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0100<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0900<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">9 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1700<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">5 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0200<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">2 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1000<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">10 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1800<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">6 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0300<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">3 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1100<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">11 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1900<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">7 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0400<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">4 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1200<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">Noon<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">2000<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">8 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0500<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">5 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1300<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1 pm<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">2100<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">9 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0600<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">6 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1400<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">2 pm<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">2200<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">10 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr class=\"border\" style=\"height: 14px\">\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">0700<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">7 am<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">1500<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">3 pm<\/p>\r\n<\/td>\r\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">2300<\/p>\r\n<\/td>\r\n<td style=\"width: 16.6667%;height: 14px\">\r\n<p class=\"no-indent\">11 pm<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<strong>Figure 1:<\/strong> The 24-hour clock and standard time.\r\n<div><\/div>\r\n<div><\/div>\r\n<div><\/div>\r\n<div><\/div>\r\n<div><\/div>\r\n<div><\/div>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip\u00a0<\/strong><\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p class=\"no-indent\"><strong>The 24-hour Clock<\/strong><\/p>\r\n<p class=\"no-indent\">Understanding the 24-hour clock can be confusing after 1 pm (standard time). Simply add or subtract when converting: for example, if the standard time is 2:15 pm, add 12 hours for the 24-hour clock time of 1415. If you are provided the time of 2230, subtract 12 hours for the standard time of 10:30 pm. <strong>\u00a0<\/strong><\/p>\r\n\r\n<\/div>\r\n<\/div>\r\n&nbsp;\r\n\r\n&nbsp;\r\n\r\n<strong>Table 5<\/strong> focuses on information security: the requirement that \"nurses secure and protect personal health information by maintaining privacy and confidentiality, which includes acting in accordance with relevant legislation, standards of practice and employer\/organizational policies\u201d (CNO, 2025, p. 10).\r\n\r\n<strong>\u00a0<\/strong>\r\n\r\n<strong>Table 5:<\/strong> Information security\r\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%\" border=\"0\">\r\n<tbody>\r\n<tr>\r\n<td class=\"shaded\" style=\"width: 33.3333%\"><strong>Indicator<\/strong><\/td>\r\n<td class=\"shaded\" style=\"width: 33.3333%\"><strong>Consideration\u00a0<\/strong><\/td>\r\n<td class=\"shaded\" style=\"width: 33.3333%\"><strong>Additional EHR Considerations<\/strong><\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\u201cWho has the right to <strong>access<\/strong> the client\u2019s health record?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">You and any other healthcare provider have the right to access the client record, IF you are involved in providing care for the client. You do not have the right to access a client\u2019s record if you are not a healthcare provider involved in the care for that client. Clients and their substitute decision-maker have the right to view and\/or acquire a copy of their health record \u201cunless there is a compelling reason not to do so\u201d (CNO, 2019, p. 8). For example, you may decide, in collaboration with the healthcare team, to not permit viewing of the record if this could result in harm to the client\u2019s treatment and\/or recovery. You should document when a client views the record or if a decision was made to not permit the client to do so.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">No additional considerations.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\u201cHow do I maintain <strong>confidentiality<\/strong> of client health information?\u201d<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">You are responsible for securing the client\u2019s record so that only individuals who are involved in the client\u2019s care are permitted access to it. Keep written records in a secure location. Never leave a chart open or unattended, and return it to the secure location when you are finished documenting. If it is necessary to refer to another client while documenting in a client\u2019s record, use initials to refer to the other client.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">You are responsible for ensuring that access to an EHR with your unique identifier (username and password) remains secure. Never share your login information. You should create strong passwords, change passwords regularly, and always sign out when you are done. Never leave a client\u2019s EHR open and visible to others.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\"What are my accountabilities when using <strong>artificial intelligence<\/strong> (AI) to support my documentation?<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">Typically not applicable when paper charting.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">You are responsible for obtaining informed consent when using AI. This should be done in accordance with the organization where you are employed. For example, some organizations post a written announcement on the wall indicating that AI is used.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">\"How do I ensure the security of client information upon<strong> transmission<\/strong> of information?\"<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">Ensure that only healthcare team members have access to the client record.<\/p>\r\n<\/td>\r\n<td style=\"width: 33.3333%;vertical-align: top\">\r\n<p class=\"no-indent\">Secure messaging and technologies should be used when transmitted information electronically.<\/p>\r\n<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n&nbsp;\r\n\r\n&nbsp;\r\n<div class=\"textbox textbox--exercises\"><header class=\"textbox__header\">\r\n<p class=\"textbox__title no-indent\" style=\"text-align: center\"><strong>Points of Consideration<\/strong><\/p>\r\n\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n<p class=\"no-indent\">Many <strong>abbreviations <\/strong>and<strong> symbols<\/strong> used in healthcare have multiple meanings and can be incorrectly interpreted by others. Only use abbreviations and symbols that are included on an approved list in the organization where you practice; if there is no list, don\u2019t use any. The use of structured data elements is one advantage of EHRs in ensuring consistency in the meaning of terms. When documenting unstructured data elements, the same considerations as paper records apply.<\/p>\r\nIn <strong>paper charting<\/strong>, always document in the next available space. For example, in a written progress note, document on the next line; on a vital sign graph, document in the next column. Never leave empty spaces. In a progress note, if there is insufficient space to write a word on a line, draw a line and continue your note in the next line. If there is insufficient space to complete your note towards the end of a page, write \"continued on next page\" and sign your name and designation. Then, on the next page, re-enter the date, time, and write \"continued note.\" EHRs differ in terms of layout and interface; you will become familiar with the conventions used in each. One benefit of EHR is that documentation is automatically is inserted in the next available space, so no empty space or lines are left.\r\n\r\n<\/div>\r\n<\/div>\r\n&nbsp;\r\n<h2>Activity: Check Your Understanding<\/h2>\r\n[h5p id=\"7\"]\r\n\r\n&nbsp;\r\n\r\n&nbsp;\r\n\r\n<img src=\"http:\/\/pressbooks.library.ryerson.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-1024x378.jpg\" alt=\"\" width=\"1024\" height=\"378\" class=\"alignnone size-large wp-image-232\" \/>\r\n\r\n[h5p id=\"14\"]\r\n\r\n<header>\r\n<h1 class=\"entry-title\">References<\/h1>\r\n<\/header>\r\n<p class=\"no-indent\">College of Nurses of Ontario (2025).<span>\u00a0<\/span><em>Documentation<\/em>.<span>\u00a0<\/span><a href=\"https:\/\/www.cno.org\/globalassets\/docs\/prac\/41001_documentation.pdf\">https:\/\/www.cno.org\/globalassets\/docs\/prac\/41001_documentation.pdf<\/a><\/p>","rendered":"<p>As a nurse, you are legally obligated to complete documentation. You should refer to the <strong>legislative<\/strong> and <strong>regulatory requirements<\/strong> for documentation in the province or territory that you work. In Ontario, you should first <strong>closely review<\/strong> the Documentation practice standard found at: <a href=\"https:\/\/cno.org\/Assets\/CNO\/Documents\/Standard-and-Learning\/Practice-Standards\/41001_documentation.pdf\" target=\"_blank\" rel=\"noopener\">CNO Documentation<\/a><\/p>\n<p>As per the CNO (2025), there are three documentation principles:<\/p>\n<ul>\n<li>Communication.<\/li>\n<li>Documentation requirements.<\/li>\n<li>Information security.<\/li>\n<\/ul>\n<p>There are several indicators that facilitate nurses\u2019 application of the three documentation principles to their practice. <strong>Table 3, 4, and 5<\/strong> present common questions related to the indicators for the above three principles.<\/p>\n<p><strong>Table 3<\/strong> focuses on communication: the requirement that \u201cEffective communication is a foundational documentation accountability that promotes safe and quality nursing care. Nurses must apply their knowledge, skill and judgment when documenting, ensuring their documentation is a clear, complete and accurate representation of the client\u2019s health status including the nursing care provided and any significant interactions.\u201d (CNO, 2025, p. 6).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Table 3:<\/strong> Communication<\/p>\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr>\n<td class=\"shaded\" style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\"><strong>Questions<\/strong><\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\"><strong>Considerations<\/strong><\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\"><strong>Additional EHR Considerations<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">\u201cWhat does it mean to document both <strong>objective<\/strong> and <strong>subjective<\/strong> data?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">In addition to providing care, you must document using a combination of subjective (what the client says) and objective (what you observe) data.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">Comprehensive documentation of subjective and objective data will require using both structured and unstructured data elements.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">\u201cHow do I ensure that my documentation is a <strong>complete record<\/strong> of the nursing process?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">A complete record includes of all phases of the nursing process: assessment (e.g., subjective and objective data); plan of care and interventions (e.g., hygiene care, assistance with mobility, treatments such as turning the client and medications, health teaching); and evaluation of the care you provide (e.g., how did the client respond?). In addition, a complete record includes all relevant communication and attempts at communication with the healthcare team including the client and family. CNO (2025) indicates that documentation of communication should include the communication mode, the person&#8217;s name and designated title (when applicable), and the discussion outcome.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">No additional considerations.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">\u201cWhat do I need to consider so that my documentation is <strong>clear<\/strong>, <strong>relevant<\/strong>, <strong>individualized<\/strong> to the client, and with <strong>minimal duplication<\/strong>?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">Your documentation must be precise and coherent so others can understand. Vague and obscure documentations can lead to misinterpretation.<\/p>\n<p class=\"no-indent\">Documentation should be specific and individualized to each client.<\/p>\n<p class=\"no-indent\">Your documentation should balance being comprehensive and concise. This will become easier with practice. Try to include all relevant information and omit unimportant information. For example, a client may tell you a story that is irrelevant to their reasons for seeking care or your assessment; do not include this. Try to be succinct and avoid documenting the same thing twice.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">Structured data should be entered according to the structures included in the EHR. For example, the EHR may require a specific format to enter the value for the field \u201cblood pressure.\u201d<\/p>\n<p class=\"no-indent\">Unstructured data should be documented using the same best practices as those used for paper documentation.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">\u201cHow do I ensure that my documentation is <strong>free from discrimination<\/strong>?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">You are responsible for adhering to the <a href=\"https:\/\/www.ontario.ca\/laws\/statute\/90h19?search=ontario+human+rights+code\" target=\"_blank\" rel=\"noopener\">Ontario Human Rights Code<\/a> Ontario Human Rights Code when documenting. This means that you should be respectful of a client&#8217;s identity and how you refer to it in your entries (e.g., race, ethnic origin, citizenship, sex, sexual orientation, gender identity, gender expression). As an example, you should be respectful of how a client self identifies (e.g., pronoun usage).<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">No additional considerations.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Table 4<\/strong> focuses on documentation requirements: the requirement that documentation is \u201cconsistent, appropriate, and accurate &#8230; [and] support accessibility, ensure continuity, and uphold legal as well as professional accountabilities\u201d (CNO, 2025, p. 8).<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Table 4:<\/strong> Documentation requirements<\/p>\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%;height: 1029px\">\n<tbody>\n<tr style=\"height: 30px\">\n<td class=\"shaded\" style=\"width: 33.3333%;height: 30px\">\n<p class=\"no-indent\"><strong>Indicator<\/strong><\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 33.3333%;height: 30px\">\n<p class=\"no-indent\"><strong>Consideration<\/strong><\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 33.3333%;height: 30px\">\n<p class=\"no-indent\"><strong>Additional EHR Considerations<\/strong><\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">\u201cHow do I record the <strong>date<\/strong> and <strong>time<\/strong> of my documentation?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">Use the 24-hour clock (also called military time; see <strong>Figure 1<\/strong>). Generally, the documentation date and time should reflect the time of your documentation entry as opposed to the time you provided the care. However, when documenting vital signs, medication administration, or other procedures, you should specifically note the time that the task was performed.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">EHRs capture your digital identity and time stamps of your activities.<\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 204px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 204px\">\n<p class=\"no-indent\">How do I ensure that a <strong>unique identifier<\/strong> is used to sign documentation entries?<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 204px\">\n<p class=\"no-indent\">First, note that \u201cregistered nurse\u201d and \u201cnurse\u201d are protected titles in Ontario, and you can only use them as a designation if you are registered with the CNO (2020). Your educational institution will discuss with you what designation you should use as a nursing student. You must provide your full legal name (printed), signature, and initials on a main sheet. Your name and designation must be consistent with your CNO registration and can only be in English or French. Typically, a signature is written in cursive (as opposed to printed) and is something that is unique to you, usually includes your first and last name or first initial and last name.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 204px\">\n<p class=\"no-indent\">EHRs provide ways of including your signature and designation electronically. They may require you to sign on and off digitally, include your digital identity, password, and time stamps of your activities, and limit or restrict access to certain functions for students.<\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 220px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 220px\">\n<p class=\"no-indent\">\u201cHow do I ensure that my documentation is <strong>timely<\/strong> and when do I indicate it as a <strong>late entry<\/strong>?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 220px\">\n<p class=\"no-indent\">You are expected to document promptly after an assessment or providing care. Do not wait until the end of your shift to document, and never document prior to providing care. Sometimes it may not be possible to document promptly because another client or nurse requires your assistance; in this case, document as quickly as you can and identify it as a \u201clate entry.\u201d You will still include the time that you are documenting, and in the first line include something like \u201cLate entry. Assessment and care provided at XX\u201d (and specify the time the care was provided). Each workplace should have policies and procedures concerning late entries; if not, you should advocate for them.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 220px\">\n<p class=\"no-indent\">Documentation date and time are captured by the EHR along with your digital identity and time stamps of your activities.<\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 61px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 61px\">\n<p class=\"no-indent\">\u201cWhat does it mean to document in a <strong>chronological order<\/strong>?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 61px\">\n<p class=\"no-indent\">Chronological order means that your documentation is arranged in order of time: from what happened first to what happened last.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 61px\">\n<p class=\"no-indent\">No additional considerations.<\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\u201cWhat should I consider in terms of ensuring my hand-written documentation is <strong>legible<\/strong> and completed in <strong>permanent ink<\/strong>?\u201d<\/p>\n<p class=\"no-indent\">\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">Your hand-written documentation must be legible, meaning that it can be read and understood by others: if your cursive writing is poor, consider printing. Permanent ink is specified because you are generally not permitted to use pencil to document. Black ink is usually best because it yields the best photocopies, but red and blue ink is required for certain vital sign graphs.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">One advantage of EHRs is the avoidance of legibility issues related to hand-written documentation.<\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 93px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 93px\">\n<p class=\"no-indent\">\u201c<strong>Who<\/strong> should complete the documentation note?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 93px\">\n<p class=\"no-indent\">Only document your own observations and actions. Do not document the observations and actions of other healthcare providers except in situations where you are a designated recorder, such as during code situations. Co-signing of documentation notes is not permitted.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 93px\">\n<p class=\"no-indent\">No additional considerations.<\/p>\n<\/td>\n<\/tr>\n<tr style=\"height: 125px\">\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">\u201cHow do I <strong>correct<\/strong> a documentation note when an <strong>error<\/strong> is made while documenting?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">It is vital that any error in a written documentation note remains visible. Do not scribble over the error or use correction fluid. Unless there is a specific organizational policy, draw a single line through the error and initial it. Some organizations have policies such as writing the word \u201cerror\u201d and including the date\/time and your signature.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top;height: 125px\">\n<p class=\"no-indent\">In an EHR, you can add an additional note referencing the error. It will capture this information along with your digital identity and time stamps of your activities.<\/p>\n<p class=\"no-indent\">Some EHRs have specific functions to address errors in documentation. You will become familiar with the conventions used in each.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<table class=\"grid\" style=\"border-collapse: collapse;width: 100%;height: 126px\">\n<tbody>\n<tr style=\"height: 14px\">\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\"><strong>24-hour clock<\/strong><\/p>\n<\/th>\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\"><strong>Standard time<\/strong><\/p>\n<\/th>\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\"><strong>24-hour clock<\/strong><\/p>\n<\/th>\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\"><strong>Standard time<\/strong><\/p>\n<\/th>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\"><strong>24-hour clock<\/strong><\/p>\n<\/td>\n<th class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\"><strong>Standard time<\/strong><\/p>\n<\/th>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0000<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">midnight<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0800<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">8 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1600<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">\u00a04 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0100<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0900<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">9 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1700<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">5 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0200<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">2 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1000<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">10 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1800<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">6 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0300<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">3 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1100<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">11 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1900<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">7 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0400<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">4 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1200<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">Noon<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">2000<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">8 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0500<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">5 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1300<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1 pm<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">2100<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">9 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0600<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">6 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1400<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">2 pm<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">2200<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">10 pm<\/p>\n<\/td>\n<\/tr>\n<tr class=\"border\" style=\"height: 14px\">\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">0700<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">7 am<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">1500<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">3 pm<\/p>\n<\/td>\n<td class=\"shaded\" style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">2300<\/p>\n<\/td>\n<td style=\"width: 16.6667%;height: 14px\">\n<p class=\"no-indent\">11 pm<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p><strong>Figure 1:<\/strong> The 24-hour clock and standard time.<\/p>\n<div><\/div>\n<div><\/div>\n<div><\/div>\n<div><\/div>\n<div><\/div>\n<div><\/div>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip\u00a0<\/strong><\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p class=\"no-indent\"><strong>The 24-hour Clock<\/strong><\/p>\n<p class=\"no-indent\">Understanding the 24-hour clock can be confusing after 1 pm (standard time). Simply add or subtract when converting: for example, if the standard time is 2:15 pm, add 12 hours for the 24-hour clock time of 1415. If you are provided the time of 2230, subtract 12 hours for the standard time of 10:30 pm. <strong>\u00a0<\/strong><\/p>\n<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><strong>Table 5<\/strong> focuses on information security: the requirement that &#8220;nurses secure and protect personal health information by maintaining privacy and confidentiality, which includes acting in accordance with relevant legislation, standards of practice and employer\/organizational policies\u201d (CNO, 2025, p. 10).<\/p>\n<p><strong>\u00a0<\/strong><\/p>\n<p><strong>Table 5:<\/strong> Information security<\/p>\n<table class=\"lines\" style=\"border-collapse: collapse;width: 100%\">\n<tbody>\n<tr>\n<td class=\"shaded\" style=\"width: 33.3333%\"><strong>Indicator<\/strong><\/td>\n<td class=\"shaded\" style=\"width: 33.3333%\"><strong>Consideration\u00a0<\/strong><\/td>\n<td class=\"shaded\" style=\"width: 33.3333%\"><strong>Additional EHR Considerations<\/strong><\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">\u201cWho has the right to <strong>access<\/strong> the client\u2019s health record?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">You and any other healthcare provider have the right to access the client record, IF you are involved in providing care for the client. You do not have the right to access a client\u2019s record if you are not a healthcare provider involved in the care for that client. Clients and their substitute decision-maker have the right to view and\/or acquire a copy of their health record \u201cunless there is a compelling reason not to do so\u201d (CNO, 2019, p. 8). For example, you may decide, in collaboration with the healthcare team, to not permit viewing of the record if this could result in harm to the client\u2019s treatment and\/or recovery. You should document when a client views the record or if a decision was made to not permit the client to do so.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">No additional considerations.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">\u201cHow do I maintain <strong>confidentiality<\/strong> of client health information?\u201d<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">You are responsible for securing the client\u2019s record so that only individuals who are involved in the client\u2019s care are permitted access to it. Keep written records in a secure location. Never leave a chart open or unattended, and return it to the secure location when you are finished documenting. If it is necessary to refer to another client while documenting in a client\u2019s record, use initials to refer to the other client.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">You are responsible for ensuring that access to an EHR with your unique identifier (username and password) remains secure. Never share your login information. You should create strong passwords, change passwords regularly, and always sign out when you are done. Never leave a client\u2019s EHR open and visible to others.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">&#8220;What are my accountabilities when using <strong>artificial intelligence<\/strong> (AI) to support my documentation?<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">Typically not applicable when paper charting.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">You are responsible for obtaining informed consent when using AI. This should be done in accordance with the organization where you are employed. For example, some organizations post a written announcement on the wall indicating that AI is used.<\/p>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">&#8220;How do I ensure the security of client information upon<strong> transmission<\/strong> of information?&#8221;<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">Ensure that only healthcare team members have access to the client record.<\/p>\n<\/td>\n<td style=\"width: 33.3333%;vertical-align: top\">\n<p class=\"no-indent\">Secure messaging and technologies should be used when transmitted information electronically.<\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<div class=\"textbox textbox--exercises\">\n<header class=\"textbox__header\">\n<p class=\"textbox__title no-indent\" style=\"text-align: center\"><strong>Points of Consideration<\/strong><\/p>\n<\/header>\n<div class=\"textbox__content\">\n<p class=\"no-indent\">Many <strong>abbreviations <\/strong>and<strong> symbols<\/strong> used in healthcare have multiple meanings and can be incorrectly interpreted by others. Only use abbreviations and symbols that are included on an approved list in the organization where you practice; if there is no list, don\u2019t use any. The use of structured data elements is one advantage of EHRs in ensuring consistency in the meaning of terms. When documenting unstructured data elements, the same considerations as paper records apply.<\/p>\n<p>In <strong>paper charting<\/strong>, always document in the next available space. For example, in a written progress note, document on the next line; on a vital sign graph, document in the next column. Never leave empty spaces. In a progress note, if there is insufficient space to write a word on a line, draw a line and continue your note in the next line. If there is insufficient space to complete your note towards the end of a page, write &#8220;continued on next page&#8221; and sign your name and designation. Then, on the next page, re-enter the date, time, and write &#8220;continued note.&#8221; EHRs differ in terms of layout and interface; you will become familiar with the conventions used in each. One benefit of EHR is that documentation is automatically is inserted in the next available space, so no empty space or lines are left.<\/p>\n<\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<h2>Activity: Check Your Understanding<\/h2>\n<div id=\"h5p-7\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-7\" class=\"h5p-iframe\" data-content-id=\"7\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Principles of Documentation\"><\/iframe><\/div>\n<\/div>\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"http:\/\/pressbooks.library.ryerson.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-1024x378.jpg\" alt=\"\" width=\"1024\" height=\"378\" class=\"alignnone size-large wp-image-232\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-1024x378.jpg 1024w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-300x111.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-768x284.jpg 768w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-1536x567.jpg 1536w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-2048x756.jpg 2048w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-65x24.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-225x83.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-content\/uploads\/sites\/122\/2020\/08\/Principles-of-Documentation-Activity-350x129.jpg 350w\" sizes=\"auto, (max-width: 1024px) 100vw, 1024px\" \/><\/p>\n<div id=\"h5p-14\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-14\" class=\"h5p-iframe\" data-content-id=\"14\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Principles of Documentation 2\"><\/iframe><\/div>\n<\/div>\n<header>\n<h1 class=\"entry-title\">References<\/h1>\n<\/header>\n<p class=\"no-indent\">College of Nurses of Ontario (2025).<span>\u00a0<\/span><em>Documentation<\/em>.<span>\u00a0<\/span><a href=\"https:\/\/www.cno.org\/globalassets\/docs\/prac\/41001_documentation.pdf\">https:\/\/www.cno.org\/globalassets\/docs\/prac\/41001_documentation.pdf<\/a><\/p>\n","protected":false},"author":34,"menu_order":5,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-29","chapter","type-chapter","status-publish","hentry"],"part":3,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/29","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":37,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/29\/revisions"}],"predecessor-version":[{"id":332,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/29\/revisions\/332"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/parts\/3"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapters\/29\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/media?parent=29"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/pressbooks\/v2\/chapter-type?post=29"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/contributor?post=29"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/documentation\/wp-json\/wp\/v2\/license?post=29"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}