CNO - College of Nurses of Ontario Documentation and Reporting Standards Questions and Answers

Question 1

A nurse documents an assessment at 10:00 but does not have time to enter it into the electronic health record (EHR) until 13:00.
Which action is most appropriate for the nurse to take when documenting the assessment?

Accepted Answer

Document the current time (13:00) in the entry and state that the assessment was completed at 10:00.

Answer

Change the computer's time to 10:00 before making the entry to ensure chronological order.

Answer

Document the entry with a time of 10:00 and add a note in the comments about the delay.

Answer

Ask a colleague who was free at 10:00 to enter and sign the assessment on their behalf.

Question 2

Which of the following is considered the primary purpose of nursing documentation according to the CNO's 'Documentation' practice standard?

Accepted Answer

To facilitate communication among healthcare providers for the continuity of client care.

Answer

To provide data for quality improvement initiatives and nursing research.

Answer

To create a legal record to protect the nurse and the employer from litigation.

Answer

To serve as a tool for evaluating a nurse's professional practice and performance.

Question 3

A nurse has been charged with an offence under the Criminal Code of Canada that is unrelated to their nursing practice. According to the Regulated Health Professions Act, 1991, what is the nurse's reporting obligation to the CNO?

Accepted Answer

The nurse must self-report the charge in writing to the CNO.

Answer

The nurse must report the charge to their employer, who is then responsible for reporting to the CNO.

Answer

The nurse is only required to report the charge if they are found guilty.

Answer

The nurse has no obligation to report the charge as it did not occur in the workplace.

Question 4

While reviewing a client's electronic chart, a nurse notices an incorrect medication dosage was documented by a colleague on a previous shift. The client did not suffer any adverse effects. What is the nurse's most appropriate initial action?

Accepted Answer

Discuss the error with the colleague who made the entry and instruct them on how to correct it.

Answer

Delete the incorrect entry to prevent future confusion for the healthcare team.

Answer

Report the error immediately to the unit manager for disciplinary action.

Answer

Add a new entry to the chart clarifying the error and the correct information.

Question 5

A nurse is documenting care in a shared electronic health record. Which of the following entries best demonstrates the use of objective, factual language as required by CNO standards?

Accepted Answer

Client grimaced and pulled away during dressing change, stating, 'That hurts a lot.'

Answer

Client appeared anxious and was uncooperative during dressing change.

Answer

Client is complaining of significant pain in his abdomen again.

Answer

Client's daughter is angry about the delay in her father's discharge.

Question 6

Under Ontario's Personal Health Information Protection Act, 2004 (PHIPA), a nurse understands that they are a 'health information custodian'. This role primarily obligates the nurse to:

Accepted Answer

Safeguard client information, ensuring it is collected, used, and disclosed only as permitted by law.

Answer

Obtain express written consent before sharing any information with other members of the direct care team.

Answer

Ensure all personal health information is permanently deleted upon the client's discharge.

Answer

Allow any family member to access a client's health record upon verbal request.