Considerations when using artificial intelligence for documentation
The updated Documentation practice standard is now in effect.
Over the next months, we will spotlight a few key topics from the new Documentation practice standard. We hope this will help nurses, employers and other system partners understand these topics as they incorporate them into safe nursing practice.
The first topic in the series is focused on nursing accountability when using artificial intelligence (AI) in documentation. CNO recognizes that AI technologies are already being used in many practice settings to support documentation by capturing and summarizing interactions with clients into electronic records. This is why we included expectations for the use of AI in the Documentation standard. At the core of these expectations is the understanding that AI is a support tool, not a substitute for your nursing knowledge, skill and judgment.
Know your accountability
Nurses are accountable for ensuring documentation created with AI tools is accurate and reflects clinical judgment. It is important to review all documentation for completeness and correctness before it becomes a part of the permanent record.
Ensure accuracy
AI tools may be helpful, but they also have risks and limitations. They may produce errors, omit important details or reflect biased or generalized information. To ensure accuracy, the nurse that is accountable for the documentation must review, verify and correct the information generated by AI before it becomes a part of the permanent record.
It is also important to consider how AI tools are trained. Depending on the data set, an AI tool may misinterpret cultural, linguistic or setting-specific nuances. In acute care, for example, clinical details such as the reason for telemetry monitoring, changes in cardiac rhythm or your nursing interpretation of findings are essential. An AI scribe may not capture these details adequately, so it is your responsibility to verify that the documentation accurately reflects the client’s condition and ongoing surveillance you provide.
Uphold documentation requirements
Whether documentation is generated solely by you or with the support of AI, the same standards apply. This means your finalized documentation must be:
- accurate and timely
- clear, complete and client-centred
- reflective of the nurse’s clinical reasoning
- compliant with organizational policies and legislative requirements.
Finally, make sure any AI tool you use has been approved by your employer and you follow the employer’s policies for AI use. If you are using an AI scribe that actively listens during a client encounter, be sure to obtain the client’s consent, as private health information is being collected.
For more information on this topic, you may find CNO’s guidance on AI in nursing practice helpful. If you have more questions about using AI in your documentation, our practice support team is always available to help.