PIE Charting

[Neon8]

I have the concept down of PIE charting: You state the problem, you do an intervention, and then evaluate. I bought a book on documentation even. Here's my problem: I need EXAMPLES of how things are WORDED when charting. Anyone know of any sites/books that have examples to go by?

[DIPLOMATICRN4HIRE, MSN, RN]

Think of it like this

P-problem-disease process (whats going on with your patient at assessment)

I-intervention-what you did to assist or implement to eleviate the problem at hand

E-evaluation- how your intervention worked

Do your patient assessment:

ie: Patient admitted with SOB, noted o2 sats at 85% on room air

P-SOB,sats

I-O2 started at ---- dosage, Dr notified , restrictive clothing removed , Dr notified awaiting orders

E-sats >90, no complaints of SOB at this time, Orders from Dr recieved. Patient denys discomfort and sob at this time will continue to evaluate status.

Put each situation into the PIE. It may take awhile and there are many interventions , thats ok

there will be many problems , many interventions, evaluations need to be specific for each problem.Interventions can be used for multiple problems.

I do know of any sites but if you look in your care plan books you can find the Basic PIE charting.

Zoe

[boggle, ASN, RN]

I have used PIE and SOAP and greatly prefer PIE ! I consider the P really the same as the S and O. You are stating the problem in patient's Subjective and nurses Objective terms.

Sometimes the I and E sections get repeated when the first Intervention was not effective and another Intervention had to be added (leading to another Evaluation, and so on....)

[NicuGal, MSN, RN]

P: O2 requirement

I: Weaned O2 today, increased Lasix dose.

E: Tol well, no distress, PO greater than 95%. No s/s of CHF, had good output from increased Lasix. Cont to wean O2 as able, follow pulseox and follow for further s/s of CHF.

P: Sepsis

I: Fever x 2 today, Tmax 40. Lethargic. Septic w/u done, started on Abx. Given Tylenol x2.

E: Follow bld cx, labs. Administer Tylenol as ordered for fever---responded well with temp down within an hour. Cont abx as ordered. Infant more awake and alert than earlier.

[nursemouse]

It's a little off-subject but:

P: Nursing shortage resulting in poor patient care.

I: Appropriate salaries for nursing faculty.

O: Quality nursing faculty in adequate numbers recruited to excellent nursing programs, enabling the admission of increased number of nursing students and graduation of well-trained nurses.

(Hey: I can always dream...):)

[gradRN2007, BSN, RN]

always did charting by exception then went computerized...yipppeeee

now learning PIE charting at new facility, computers next year..RT/PT/RN/etc all use same paper so before you turn around with your time sounds like there could be 10 entries and you still need 0800 and its 1200...does this happen always