Documenting Problems:
Recording Data

Tool #3

Click here to download pdf version of Tool #3.

What Evidence Do I Need to Document the Problem?

Purpose
This worksheet will help you to identify the evidence needed to fully document your problem.

Procedure

• Review the questions below and gather the evidence you need to document your problem. Discuss with a colleague.
• You can also use this tool to develop a presentation on the evidence you need to gather.

Step 1: Define Evidence

Step 2: Identify the Evidence
To identify the evidence required to objectively and professionally describe the problem that is interfering with your practice, ask yourself the following questions in relation to the problem.

1. What happened?
2. When did it happen? What time did it occur? What date?
3. Who was involved?
4. What were the circumstances at the time of the problem?
5. What action was taken? By whom?
6. What happened as a result of the action (or no action)?

Tip!
Keep your feelings about what happened separate from your official documentation of the problem.

Step 3: Gather the Evidence
Remember, no analysis of the situation is required at this time. Focus your evidence gathering on observable facts.

Step 4: Document the Evidence

• Use the data collection tool (part 2 of this worksheet) to help you collect and organize yoru thoughts and record the evidence in an accurate and deliberate manner.
• Maintain confidentiality; do not identify clients by name.
• Keep a copy of this data collected in your records, and use this to help inform your written communications.

Download and print the data collection tool, click here.