PROBLEM INTERVENTION

EVALUATION (PIE)
METHOD
 INTRODUCTION
Documentation is not separate from care and it is not optional. It is an
integral part of registered nurse practice, and an important tool that RNs use
to ensure high-quality client care. The term “documentation” refers to: any
written or electronically generated information about a client that describes
client status or the care or services provided to that client.
• Recording and reporting are the major ways health care providers
communicate.
• The client’s medical record is a legal document of all activities regarding
client care
 DEFINITION
• Documentation is the written legal record of all pertinent interactions with
the client - Assessing , diagnosing, planning, implementing and evaluating
• Documentation is any written or electronically generated information about
a client that describes the status, care or services provided to that client.
Through documentation, you communicate observations, decisions, actions
and outcomes of these actions for clients, demonstrating the nursing process.
For the purpose of this document, client may be an individual, family, group,
community or population.
 PURPOSES OF DOCUMENTATION
1. COMMUNICATION.
Communication Provides efficient and effective method of sharing information.
2.LEGAL DOCUMENTATION.
It is admissible as evidence in a court of law.
3. RESEARCH.
Provides valuable health-related data research.
4. STATISTICS.
Provides statistical information that can be utilized for planning people’s future needs.
5. EDUCATION.
Serves as an educational tool for students in health discipline.
 PURPOSES OF DOCUMENTATION
6. AUDIT & QUALITY ASSURANCE.
Monitors the quality of care received by the client and thecompetence of health care givers.
7. PLANNING CLIENT CARE.
Provides data which the entire health team uses to plan care for the client.
8. REIMBURSEMENT.
Provides the basis for decisions regarding care to be provided and subsequent regarding
care to be provided and subsequent reimbursement to the agency, to cover health-
reimbursement to the agency, to cover health- related expenses.
 PRINCIPLES AND GUIDELINES FOR
QUALITY DOCUMENTATION
 Factual
 Accurate
 Completeness
 Current
 Organized
 Timings
 METHODS OF DOCUMENTATION
• Narrative Charting
• Source-Oriented Charting
• Problem-Oriented Charting
• PIE Charting
• Focus Charting
• Charting by Exception (CBE)
• Computerized Documentation
• Case Management with Critical Paths
 INTRODUCTION
• PIE charting was developed by nurses at the Craven Regional Medical
Center to streamline documentation.
• “PIE” stands for Problem, Intervention, and Evaluation.
• PIE charting eliminates the need for the traditional nursing care plan
because the ongoing plan of care is incorporated into daily
documentation. 
• It is a systematic approach of documenting to nursing process or nursing
diagnosis.
PROBLEM-INTERVENTION-EVALUATION SYSTEM

• The PIE system organizes information according to patients’

problems. It requires that you keep a daily assessment flow sheet
and progress notes. Integrating the care plan into the nurses’
progress notes eliminates the need for a separate care plan and
provides a record that has a nursing—rather than medical—focus.
• The daily assessment flow sheet includes areas for documenting
assessment of major categories, such as respiration or pain, along
with routine care and monitoring.
• It usually provides spaces to document times treatments were
given as well as continued assessments of a specific area such as
neurologic checks every hour.
• Progress notes are organized according to PIE:
• The PIE notes are numbered or labeled according to the client’s problems.
Resolved problems are dropped from daily documentation after the RN’s
review. Continuing problems are documented daily (Potter et al., 2006 ) 
 PROBLEM

• Use data collected from your initial assessment to identify pertinent nursing
diagnoses.
• Use the list of nursing diagnoses accepted by your facility, which usually
corresponds to the diagnoses approved by the North American Nursing Diagnosis
Association (NANDA).
• Some facilities use a separate problem list such as in the POMR.
• When documenting a problem in the progress notes, label it as P and number it.
• for example, P#1. This way you can refer to it later by number without having to
re-document the problem statement.
 INTERVENTION

• Document the nursing actions you take for each nursing diagnosis.
• Label each entry as followed by P and the problem number.
• for example, IP#1.
 EVALUATION

• The patient’s response to treatment makes up your evaluation.

• Use the label E followed by P and the problem number.
• for example, EP#1.
VALIDATION OF NURSING PROCESS
Name or no. Of
nursing
diagnosis being
addresed from Diagnosis and
PROBLEM written problem outcome
list, and identification
identified
outcome of that
problem
VALIDATION OF NURSING PROCESS

Nursing
action
performed Plan and
INTERVENTION
directed at implementatio
problem n
resolution
VALIDATION OF NURSING PROCESS
Appraisal of
client
responses to
EVALUATION determine Evaluation
effectiveness of
nursing
interventions
P #1: nausea related to anesthetic.
I p#1: pt. given compazine 1 mg iv at 2300.
E p#1: vomited 100 ml clear fluid at 2255. pt. now states no nausea after given compazine
P #2: risk for infection related to incision sites.
I p#2: drainage from jackson-pratt drain measured. site monitored for redness, drainage and swelling.
temperature monitored.
E p#2: incision site in front of left ear extending down and around the ear and into neck--approximately
6 " in length--without dressing. no swelling or bleeding, bluish discoloration below left ear noted, sutures
intact. jp drain in left neck below ear with 20 ml of bloody drainage. drain remains secured in place with
suture.