The hopsital I do my clinicals at, uses PIE charting, can anyone out there help me! I came up with my NANDA nursing diagnosis, and my R/T and AEB, however the problem, I have is where to chart my findings during my assessment, do I chart them under the Problem column or the Intervention column, are there any online resources that could help me? Thanks to anyone who can help!:uhoh21:
Oct 5, '06
I you are talking about making your daily progress (documentation) note on the patient's chart then you need to follow the facility policy. If you weren't oriented as to the correct way to properly record nursing progress notes in a patient's chart, then I would suggest you either call someone in the hospital's nursing education department to get this information and a set of guidelines or check their policy and procedure manual to see if there is an actual written policy that specifically states how this is to be done. Remember that the patient's chart is a legal record. It is in the facility's best interest for everyone to be following facility policies on documentation. Part of orientation for newly hired nurses is instruction with them on how to properly document on the records of that facility.