These 3 sections, Purpose, Intervention and Effectiveness are standard to a PIE Note, meaning these are the system defaults. There are options for customizing note templates if need be. If for example, any of the sections require a different name, custom labels can be created.Jun 15, 2015
PIE Acronym for a process-oriented documentation system. The progress notes in the patient record use (P) to define the particular P roblem; (I) to document I ntervention; and (E) to E valuate the patient outcome. PIE charting integrates care planning with progress notes.
How do you make a pie note?
https://www.youtube.com/watch?v=LdVFJy_V-Gk
How do I document good nursing notes?
- Be Accurate. Write down information accurately in real-time. ...
- Avoid Late Entries. ...
- Prioritize Legibility. ...
- Use the Right Tools. ...
- Follow Policy on Abbreviations. ...
- Document Physician Consultations. ...
- Chart the Symptom and the Treatment. ...
- Avoid Opinions and Hearsay.
What should you not chart in nursing notes?
- Don't chart a symptom such as “c/o pain,” without also charting how it was treated.
- Never alter a patient's record - that is a criminal offense.
- Don't use shorthand or abbreviations that aren't widely accepted.
- Don't write imprecise descriptions, such as "bed soaked" or "a large amount"
What does pie stand for in charting?
To address a number of difficulties with nursing documentation, a process-oriented documentation system called the Problem-Intervention-Evaluation (PIE) system was developed and implemented on a 35-bed medical unit at Craven County Hospital, New Bern, North Carolina.
What are the different types of documentation in nursing?
What are 4 components of correct nursing documentation?
- Chart in the correct record. ...
- Chart promptly. ...
- Be accurate, objective, and complete. ...
- Track test results and consultation reports. ...
- Avoid repetitive copying and pasting. ...
- Use approved abbreviations. ...
- Include patient communication. ...
- Record instances of non-adherence.