List the topic and include the citation for the systematic review you have selected:

 

 

What is the practice issue you have identified related to the topic you have chosen?

 

 

Define the scope of the practice issue:

 

 

What is the practice area?

___ Clinical

___ Education

___ Administration

___ Other (List):

 

 

How was the practice issue identified? (check all that apply)

___ Safety/risk management concerns

___ Unsatisfactory patient outcomes

___ Wide variations in practice

___ Significant financial concerns

 

 

___ Difference between hospital and community practice

___ Clinical practice issue is a concern

___ Procedure or process is a time waster

___ Clinical practice issue has no scientific base

__ Other:

Describe the rationale for your checked selections:

 

 

What evidence must be gathered? (check all that apply)

___ Literature search

___ Guidelines

___ Expert Opinion

___ Patient Preferences

___ Clinical Expertise

___ Financial Analysis

___ Standards (Regulatory, professional, community)

___ Other

 

Describe the rationale for your checked selections: