So my pie notes suck.........

I'm just a student so forgive my ignorance . . . but you are required to write a PIE note when there is no problem? That makes no sense to me. The definition of a pie note is PROBLEM, intervention, evaluation. We write pie notes in clinical on any problems we see. If there are no problems, we write no pie notes.

Just curious,

Kelly

I'm just a student so forgive my ignorance . . . but you are required to write a PIE note when there is no problem? That makes no sense to me. The definition of a pie note is PROBLEM, intervention, evaluation. We write pie notes in clinical on any problems we see. If there are no problems, we write no pie notes.

Just curious,

Kelly

EXACTLY! That is what I learned in nursing school. But no.

My manager wants pie notes all the time. At least two pie notes per shift. I can't even come up with one for these patients.

Hygiene? Pain, ADLS are all good topcs....

Emotional issues?

Another way of looking at this is she wants you to show active involvement wth the patient and that active care is being delivered.

Well . . . I guess if they are hospitalized there must be some problem? Find something related to their diagnosis would be my advice. Pain is always a good one, for patients who are fatigued due to illness, activity intolerance, and anxiety is also relevant in many cases, particularly if someone is having procedures done or waiting for lab or diagnostic results.

Good luck!

Kelly

Hygiene? Pain, ADLS are all good topcs....

Emotional issues?

Ok maybe you can help me with this one.

male patient, 43 years old. Came in with severe headache. Waiting on results. Pain 0 out of 10.(by the time I got him his headache was gone) Ambulates just fine. Didn't need me at all. Such a blessing on a busy night. Just hanging out and waiting. Showered by himself, ate by himself. The nurses were wondering why he was still there.

I couldn't think of one pie note. He was just waiting on the Dr. What was I supposed to chart?

Ok maybe you can help me with this one.

male patient, 43 years old. Came in with severe headache. Waiting on results. Pain 0 out of 10.(by the time I got him his headache was gone) Ambulates just fine. Didn't need me at all. Such a blessing on a busy night. Just hanging out and waiting. Showered by himself, ate by himself. The nurses were wondering why he was still there.

I couldn't think of one pie note. He was just waiting on the Dr. What was I supposed to chart?

How about anxiety regarding diagnosis? How is he coping-is he verbalizing his anxiety or in denial?

P-Reports absence of pain. Self completed ADLS.

I-Offered comfort measures. (Hungry etc.)

E-Continue to monitor pain and physical comfort levels.

I think I prefer DAP

How about anxiety regarding diagnosis?

ok. How would I pie that? He wasn't really anxious or anything. Most laid back patient I have ever seen. I asked him do you need anything? No. Questions? No. I even asked him was he worried, upset, happy? His response: No, I am just here.

THROW ME A BONE! :)

I do get alot of these by the way. We always get one of these patients for some reason. They were in pain 2 days ago and now they are just waiting. And since I am new I always get them. 1 super easy patient, and 5 not so easy patients.

P-Reports absence of pain. Self completed ADLS.

I-Offered comfort measures. (Hungry etc.)

E-Continue to monitor pain and physical comfort levels.

I think I prefer DAP

:yeah::yeah:

oh THAT IS A GOOD ONE!

THANKS!

Its going in the notebook!

So that leaves me with another question. Is it normal to have like a handful of pie notes that can be applied to different patients. For example some of the nurse have a handful of pie notes that they apply to almost everyone. At the end of their shift they have like 5 pie notes on each patient. Is that an acceptable practice?

male patient, 43 years old. Came in with severe headache. Waiting on results. Pain 0 out of 10.(by the time I got him his headache was gone) Ambulates just fine. Didn't need me at all. Such a blessing on a busy night. Just hanging out and waiting. Showered by himself, ate by himself. The nurses were wondering why he was still there

I going to assume that if was admitted because of a headache, they must be suspecting something. So I would chart this:

P - Admitted due to severe headache.

I - Currently states pain is 0 out of 10. No neurological deficits noted - pt ambulating by self, performing ADLs indepentely.

E - Pt stable. Awaiting test results.