Documentation in nursing practice is a structured process that ensures continuity of care and provides a legal record of a patient’s health status and treatment. Accurate charting minimizes errors and ensures the care team is fully informed. Various documentation models exist to streamline this process. PIE charting is one such method, designed specifically for nurses to integrate care planning directly into the patient’s progress notes.
Defining the PIE Acronym and Philosophy
PIE charting is a problem-oriented system where the acronym stands for Problem, Intervention, and Evaluation. This method integrates the patient’s care plan directly into the progress notes, eliminating the need for a separate care plan document. This design creates a record focused on the nursing process.
The “Problem” (P) element is typically a documented nursing diagnosis or an identified patient need, such as “Acute Pain” or “Impaired Skin Integrity.” Problems are documented on a patient problem list and assigned a number for easy reference in subsequent notes. This focus on the patient’s specific issues ensures that all subsequent care steps are directly related to a current, identified need.
Practical Application: How to Chart Using PIE
The PIE format guides the nurse through a specific flow of recording information, linking the identified problem to the actions taken and the resulting outcome.
Problem (P)
When charting, the nurse first identifies the “Problem” (P) and assigns it a number, which can be a new diagnosis or a continuing issue. For instance, a nurse might chart P\#1: “Acute Pain R/T surgical incision” to clearly state the problem and its cause.
Intervention (I)
The next step is “Intervention” (I), which details the specific actions performed to address the problem. The recorded interventions must directly correspond to the numbered problem, ensuring a clear link between the patient’s need and the care delivered. For example, an intervention might be I\#1: “Administered Morphine Sulfate 2mg IV per standing order at 1400.” Routine assessments and standard care actions are often documented on separate flow sheets, allowing the PIE note to focus on new or active problems.
Evaluation (E)
Finally, the nurse documents the “Evaluation” (E), which records the patient’s response to the intervention. This assesses the effectiveness of the care provided and determines if the desired outcome was achieved. The evaluation for the pain note could be E\#1: “Patient states pain is 3/10 30 minutes post-dose; appears relaxed and is resting quietly.” This chronological note structure provides a streamlined record of the care cycle.
Distinguishing PIE from Other Nursing Documentation
PIE charting is distinguished from other common documentation styles by integrating the care plan directly into the progress notes. Unlike the SOAP (Subjective, Objective, Assessment, Plan) method used in the Problem-Oriented Medical Record (POMR), PIE does not require re-documenting subjective and objective assessment data. PIE assumes that initial and routine assessment data are already recorded in comprehensive flow sheets.
The structure of SOAP focuses heavily on data collection before moving to Assessment and Plan. In contrast, PIE immediately focuses on the patient’s “Problem,” followed by the “Intervention,” and then the “Evaluation.” While DAR (Data, Action, Response) charting focuses on a specific patient “focus,” PIE is oriented around the formal “Problem,” typically a nursing diagnosis. This problem-specific focus reduces redundancy and maintains a direct line of sight from the patient’s need to the outcome.