Learning from CRNBC's Standards
Documenting Evidence: Procedure
Documentation is defined as a process of substantiating your experience of a professional practice
problem. You will consider two forms of documentation when recording the data that pertains to your problem:
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electronic documentation.
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paper documentation.
Documenting a professional practice problem
Clearly and concisely document your communication. Keep a record of all correspondence.
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Treat all documentation as confidential.
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Use a workplace letter, memo or workplace form and send in a secure manner. Also see
Tool #3.
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Include your manager's name and title in this formal communication.
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Start with a general opening statement such as: "This is a follow up to our discussion of..."
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Describe the problem: date, time, place, who was involved (use initials for names), what happened, how it affected clients, what specific Standards were reviewed and referenced.
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Include possible solutions.
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Ask for confirmation that the correspondence has been received and request a response by a specific date, allowing a reasonable amount of time for progress to occur.