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Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination
문제

Situation: A 34-year-old man with a closed fracture of the left femur is in skeletal traction on the orthopedic ward, 1 day after admission. The ward keeps a Kardex for each client and writes its nursing notes on paper. During orientation, a new nurse asks about the PIE charting format. What do its three letters stand for?

해설
PIE charting is a nursing process-based format that records the Problem, the Intervention, and the Evaluation. It differs from SOAPIE, which adds subjective, objective, assessment, and plan parts, and from focus charting, which uses Data, Action, Response.
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심화 해설

What PIE stands for
PIE charting is a documentation format built on the nursing process. Each entry is organized under three headings: Problem, Intervention, and Evaluation. PIE records the client's nursing problem, the nursing intervention carried out, and the evaluation of the client's response. Assessment data are usually recorded separately on flow sheets or daily assessment forms, and problems are numbered so that later entries can refer back to them, for example P1, I-P1, E-P1.

How a PIE entry looks
For the client in skeletal traction, a PIE entry might read: P: Acute pain related to femur fracture and muscle spasm. I: Positioned in alignment with traction, gave prescribed analgesic, applied cold as ordered. E: Pain decreased from 7 to 3 out of 10 within 45 minutes. The format keeps the note focused on the nursing problem and shows whether the intervention worked, which supports continuity of care between shifts.

Comparing common charting formats
Exams often test the letters of several formats side by side.

FormatLettersNotes
PIEProblem, Intervention, EvaluationAssessment kept on flow sheets
SOAP / SOAPIESubjective, Objective, Assessment, Plan (+ Intervention, Evaluation)Problem-oriented medical record
Focus charting (DAR)Data, Action, ResponseOrganized by a focus, not only problems
Charting by exceptionOnly abnormal findings recorded in detailRelies on standards and flow sheets

Why the distractors are wrong
Option 1 uses plan and implementation, which are nursing process steps but not the PIE headings; PIE begins with the problem. Option 3 has the right first letter, but the middle letter is intervention, and the last letter is evaluation, not evidence. Option 4 begins with plan and ends with explanation, neither of which appears in PIE.

Watch out! Do not confuse PIE with the nursing process (assessment, diagnosis, planning, implementation, evaluation). PIE is a charting format derived from it, and its first letter is Problem.

Exam takeaway
Key point! PIE equals Problem, Intervention, Evaluation; SOAPIE adds subjective, objective, assessment, and plan; focus charting uses Data, Action, Response.

임상 시나리오

PIE ChartingProblem, Intervention, Evaluation

PIE organizes each note by the Problem, the nursing Intervention, and the Evaluation of the client's response; assessment data go on flow sheets.

Example: P: Acute pain related to femur fracture. I: Aligned with traction, analgesic given. E: Pain decreased from 7 to 3 out of 10.

SOAPIE adds subjective, objective, assessment, and plan; focus charting uses Data, Action, Response.

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