Collaborating
to Resolve Practice
Problems

Documenting Problems:
Gathering Evidence

Building on Experience

As a registered nurse you are skilled at gathering and recording detailed information about your patient's status or about a situation that impacts on your client. Think of your problem or another situation where your documentation was incomplete.

  1. List the types of evidence you gathered in this situation.
  2. Identify the evidence that was not useful in this example. Why wasn't it useful?
  3. List the skills you used to gather this evidence.
  4. List the skills you used to record the data about the situation.
  5. How sharp are your skills?
    • observation
    • analysis
    • assessment 
    • critical thinking
    • recording

By analyzing previous documentation you will have a clearer picture of what aspect you wish to improve in proceeding to document your current problem.

Understanding Evidence-based Nursing Practice

Evidence-informed nursing practice forms a foundation for clinical practice and can be understood as a process of:

  • identifying a problem based on analysis of nursing knowledge and practice.
  • reviewing the literature for relevant research.
  • validating the evidence against a CRNBC Standard.
  • choosing an intervention based on the evidence.