title: The PIE system: complete planning and documentation of nursing care.
abstract: 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. The PIE system simplifies the documentation process and unifies the care plan and progress notes into a complete, concise record of nursing care actually planned and provided. Informal evaluations indicate that the PIE system increases job satisfaction for nursing staff, improves the quality of documentation, and promotes continuity of care from shift to shift and from day to day. The article raises questions for further evaluation.
mesh_terms: D006801:Humans; D009657:North Carolina; D009730:Nursing Assessment / Q000379:methods; D009732:Nursing Care / Q000379:methods*; D009736:Nursing Process / Q000379:methods; D009737:Nursing Records / Q000592:standards*