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

[chicookie]

That is it in short. My manager had a nicer way of putting it, but by the time she had finished I got the gist. My PIE notes suck. (I didn't pay attention to the rest.)

But that was her only complaint so I guess that is good.

I am looking for a book on PIE notes or any advice would be helpful!

From what I can tell my biggest problem is actually making a good pie note for when a patient really doesn't have anything. Like if they have pain or stuff going on its fine I can do one. But if they are just there waiting for test results and they are walkie-talkies I can't come up with anything. Plus I refuse to copy other nurses pie notes from the shift before. That to me is plain out lazy!

Thanks in advance!

much love,

Chicookie

[Pepper The Cat, BSN, RN]

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.

[chicookie, BSN, RN]

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.

You assume correctly. When I got him he was ok. On the chart there was nothing indicating that the MDs suspected anything. From shift report the nurse told me the doctor was feeling like it was a one time thing but ran the tests anyways just to make sure. Her words were a stress headache but the pt was worried since he didn't have headaches and came to the ED. I am thinking it must have been pretty bad in order to have admitted him.

Good PIE btw. I can never think up of anything like this. Your pies sound so....... professional. =D THANK YOU!

[eriksoln, BSN, RN]

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

Exactly. Even when the pt. is "just waiting for lab results" and stuff, you still have some sort of engagement with them.

You can write about education you performed. When I have someone waiting, for example, to find out if their coumadin (INR) is theraputic enough to go home and the primary complaint that brought them in is resolved, its during that time I focus on education.

Diet for coumadin, how to watch for signs of bleending, soft toothbrush.

Then, I go into the emotional support aspects. What if the value is not theraputic and they have to stay again? How does this affect the family system? When they do leave, are they ready, is someone going to be home with them for the first day or so if needed?

PIE, when the pt. does not have high acuity, should focus on emotional/spiritual needs and teaching. These are the aspects of pt. care most of us feel we can never give enough attention due to short staffing and other reasons. Its a good day when you run into this situation and get to give the pt. a higher level of care.

[RNperdiem, RN]

I am amazed that people actually read those notes. Are you in orientation or probation that your notes would be carefully scrutinized? If so, follow the above directions. You are being watched it would seem.

If there is something important, I will chart it in detail, otherwise I will throw in those canned phrases and do some hands on care for the patients.

[chicookie, BSN, RN]

I am amazed that people actually read those notes. Are you in orientation or probation that your notes would be carefully scrutinized? If so, follow the above directions. You are being watched it would seem.

If there is something important, I will chart it in detail, otherwise I will throw in those canned phrases and do some hands on care for the patients.

I'm in orientation. New nurse; only been on the floor a couple of weeks. So yes I am being watched very carefully. its the first complaint that she has had of me. And it wasn't even an oh you are in trouble for not charting enough it was more of a you need to improve in this area. According to her my pie notes on my other patients where ok it was in the cases like the one mentioned before that she said my charting was "lacking".

But other than that she said I was doing good.

[chicookie, BSN, RN]

Exactly. Even when the pt. is "just waiting for lab results" and stuff, you still have some sort of engagement with them.

You can write about education you performed. When I have someone waiting, for example, to find out if their coumadin (INR) is theraputic enough to go home and the primary complaint that brought them in is resolved, its during that time I focus on education.

Diet for coumadin, how to watch for signs of bleending, soft toothbrush.

Then, I go into the emotional support aspects. What if the value is not theraputic and they have to stay again? How does this affect the family system? When they do leave, are they ready, is someone going to be home with them for the first day or so if needed?

PIE, when the pt. does not have high acuity, should focus on emotional/spiritual needs and teaching. These are the aspects of pt. care most of us feel we can never give enough attention due to short staffing and other reasons. Its a good day when you run into this situation and get to give the pt. a higher level of care.

You know what I love about your posts, They are so in your face!

But you have put more thinking thoughts in my head. I did discuss some things with him, that now looking back I should have "PIE noted".

I will make a note of this!

Thank you!

[ktwlpn, LPN]

. From shift report the nurse told me the doctor was feeling like it was a one time thing but ran the tests anyways just to make sure. . =D THANK YOU!

I hope he has great insurance coverage to pay for his $100,000 workup/vacation.I wonder if he was really out of hand when he presented to the er intially. Some of the worst patients I ever had were middle aged men -just big babies...

[eriksoln, BSN, RN]

You know what I love about your posts, They are so in your face!

But you have put more thinking thoughts in my head. I did discuss some things with him, that now looking back I should have "PIE noted".

I will make a note of this!

Thank you!

Are they really? Everyone says that. Its lost on me, I dont try to be that way.

I might maybe make my avater Darth Vadar. Wooo Wooo.

[karleon]

If a headache is the problem, you could not be getting any PIE if you would not get a subjective assessment on the patient. By this you could find out that the patient might be anxious for the upcoming lab results. Further more patients like them always needs an explanation of the lab test they need so you can use knowledge deficit, or fear of the impending results. Pain is very common but you can also connect this to lack of sleep and so on..