I work in a family health team, where our organization has recently upgraded the Electronic Health Record (EHR) system by integrating artificial intelligence (AI) functionalities. While nurses continue to manually document client information in the system, the AI tool now generates summaries based on this data for operational planning and monitoring purposes. Considering these changes, would nurses need to obtain informed consent from clients regarding the implementation of AI within the EHR?
Thank you for your timely question. It’s one we hear more often as AI becomes a bigger part of clinical practice. Your situation is a great example of how these tools are starting to show up in everyday nursing work.
CNO recently updated its Documentation practice standard to reflect the growing use of technology, including AI. One of the accountabilities relates to obtaining informed consent from the client when using AI technologies for documentation purposes. For example, AI scribes, which are one of the most commonly used AI tools for documentation, transcribe and summarize conversations between health care providers and clients. Because these tools are directly recording personal health information for documentation purposes, client consent is required.
We also launched new guidance on Artificial intelligence in nursing practice that can help you understand what AI is, how it can be used to support your practice and what you need to keep in mind when integrating it into your practice.
In your question, however, you’re asking about a different use of AI tools in documentation. In your case, AI isn’t interacting with clients or collecting information directly. Instead, it’s analyzing documentation that nurses have already entered into the EHR to support internal organizational processes. When AI is used this way, the need for client consent is determined by your organization’s policies, not by CNO. Your employer is responsible for setting expectations around consent, privacy and the use of data for analytics.
For example, when using AI tools, you should ensure that client information is collected, used, disclosed, accessed and stored in ways that comply with privacy legislation and your employer policies. Similar to other digital or electronic systems, such as EHRs, AI should support safe, coordinated care while protecting client privacy and confidentiality.
As the use of AI continues to be integrated into various aspects of nursing practice, nurses remain accountable to CNO’s standards and guidelines, including those related to Documentation and Confidentiality and Privacy. We encourage you to stay familiar with updated standards, legislation and your organization’s policies so you can feel confident using AI tools safely and appropriately in your practice.
Sarah Alley, RN, BScN, MPH
Advanced Practice Consultant, Practice Quality