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    Although many attorneys are familiar with narrative charting and SOAP(IE) charting. PIE charting is less commonly encountered. The initials in PIE represent the documentation of problems, interventions, and evaluation of nursing care. The goal of PIE charting as originally designed in 1984, was to streamline documentation. This was accomplished by eliminating the traditional care plan and incorporating an ongoing plan of care into the daily documention. 1. Key elements The PIE system of charting consist of flowsheets and the progress notes. Progress notes use nursing diagnosis as the problem. The problem stetment is labeled with “P” and numbered for easy reference. For example : Date Time Progress notes ( PIE Charting ) 1/6 13.00 P#1 risk for aspiration related to decreased level of consciousness. The intervention that the nurse carried out to alleviate the nursing diagnosis are recorded netx to an “I” and are numbered to correspond to the problem. The evaluation of the effectivientions is recorded next to an “E” and numbered. For example : Date Time Progress notes ( PIE Charting) 1/6 13.00 P#1 Risk for aspiration related to decreased level of consciousness I#1 Head of bed elevated to 45 degress for one hour after eating. 14.00 E#1 No evidence of aspiration. In this system of documentation an evaluation of each problems are addressed each day until the problem resolved. 2. Medifications of PIE Charting The PIE method is often modified in one or both of the following ways : A problem list is deloved to record the patient’s identifited problems An additional entry is made in the pie note assessment findngs are added to make the actually entry apie for example 6/11 2200 a#1 disoriented to time, place and person.calling for her husband to help her get up for breakfast 1#1 reoriented patient to use call bel assitace call be placed within reach 2300 e#1 patient continue to be disoriuented.has not used call bell.calls out for her husband Advantage and disadvantage of pie charting The major advantage pie charting is thaht its format encourages the use of the nursing process by structing the progress note to include nursing diagnose,interventions and evaluation .the sytem also promotes the systematic evalution of each identifited problem once every shift The primary disadvantage of pie charting is that the planning step of the nursing process is not documented. Pie charting skips from the problem to the intervensions that we carried out.althought experienced nurses can make the leap from nursing diagnosis to intervension without documenting planning. Novice nurses often have difficulty permorming without a plan of care.staff nurses usually do not have time to review pages of progress notes to determine which approaches have been used to resolve nursing diagnoses. They often rely on change-of-shift reports to determine the important needs of the patient, as knowledgeable attorneys discover when they question nurses in depositions. Meskipun banyak pengacara yang akrab dengan narasi charting dan SOAP ( IE ) charting . PIE charting kurang umum ditemui . Inisial di PIE merupakan dokumentasi masalah , intervensi , dan evaluasi asuhan keperawatan . Tujuan dari PIE charting sebagai awalnya dirancang pada tahun 1984 , adalah untuk merampingkan dokumentasi. Hal ini dilakukan dengan menghilangkan rencana perawatan tradisional dan menggabungkan rencana perawatan berkelanjutan ke dalam dokumentasi sehari-hari. 1 . elemen-elemen kunci Sistem PIE charting terdiri dari flowsheets dan catatan perkembangan . Catatan perkembangan menggunakan diagnosis keperawatan sebagai masalah . Masalah stetment dilabeli dengan " P " dan dinomori untuk referensi mudah . Sebagai contoh: Tanggal Waktu Kemajuan catatan ( PIE Charting ) 1/6 13.00 P # 1 resiko aspirasi berhubungan dengan penurunan tingkat kesadaran . Intervensi yang dilakukan perawat untuk mengurangi diagnosis keperawatan dicatat netx ke " I " dan nomor sesuai

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    Although many attorneys are familiar with narrative charting and SOAP(IE) charting. PIE charting is less commonly encountered. The initials in PIE represent the documentation of problems, interventions, and evaluation of nursing care. The goal of PIE charting as originally designed in 1984, was to streamline documentation. This was accomplished by eliminating the traditional care plan and incorporating an ongoing plan of care into the daily documention. 1. Key elements The PIE system of charting consist of flowsheets and the progress notes. Progress notes use nursing diagnosis as the problem. The problem stetment is labeled with “P” and numbered for easy reference. For example : Date Time Progress notes ( PIE Charting ) 1/6 13.00 P#1 risk for aspiration related to decreased level of consciousness. The intervention that the nurse carried out to alleviate the nursing diagnosis are recorded netx to an “I” and are numbered to correspond to the problem. The evaluation of the effectivientions is recorded next to an “E” and numbered. For example : Date Time Progress notes ( PIE Charting) 1/6 13.00 P#1 Risk for aspiration related to decreased level of consciousness I#1 Head of bed elevated to 45 degress for one hour after eating. 14.00 E#1 No evidence of aspiration. In this system of documentation an evaluation of each problems are addressed each day until the problem resolved. 2. Medifications of PIE Charting The PIE method is often modified in one or both of the following ways : A problem list is deloved to record the patient’s identifited problems An additional entry is made in the pie note assessment findngs are added to make the actually entry apie for example 6/11 2200 a#1 disoriented to time, place and person.calling for her husband to help her get up for breakfast 1#1 reoriented patient to use call bel assitace call be placed within reach 2300 e#1 patient continue to be disoriuented.has not used call bell.calls out for her husband Advantage and disadvantage of pie charting The major advantage pie charting is thaht its format encourages the use of the nursing process by structing the progress note to include nursing diagnose,interventions and evaluation .the sytem also promotes the systematic evalution of each identifited problem once every shift The primary disadvantage of pie charting is that the planning step of the nursing process is not documented. Pie charting skips from the problem to the intervensions that we carried out.althought experienced nurses can make the leap from nursing diagnosis to intervension without documenting planning. Novice nurses often have difficulty permorming without a plan of care.staff nurses usually do not have time to review pages of progress notes to determine which approaches have been used to resolve nursing diagnoses. They often rely on change-of-shift reports to determine the important needs of the patient, as knowledgeable attorneys discover when they question nurses in depositions. Meskipun banyak pengacara yang akrab dengan narasi charting dan SOAP ( IE ) charting . PIE charting kurang umum ditemui . Inisial di PIE merupakan dokumentasi masalah , intervensi , dan evaluasi asuhan keperawatan . Tujuan dari PIE charting sebagai awalnya dirancang pada tahun 1984 , adalah untuk merampingkan dokumentasi. Hal ini dilakukan dengan menghilangkan rencana perawatan tradisional dan menggabungkan rencana perawatan berkelanjutan ke dalam dokumentasi sehari-hari. 1 . elemen-elemen kunci Sistem PIE charting terdiri dari flowsheets dan catatan perkembangan . Catatan perkembangan menggunakan diagnosis keperawatan sebagai masalah . Masalah stetment dilabeli dengan " P " dan dinomori untuk referensi mudah . Sebagai contoh: Tanggal Waktu Kemajuan catatan ( PIE Charting ) 1/6 13.00 P # 1 resiko aspirasi berhubungan dengan penurunan tingkat kesadaran . Intervensi yang dilakukan perawat untuk mengurangi diagnosis keperawatan dicatat netx ke " I " dan nomor sesuai

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    21 views4 pages

    Dokkep

    Uploaded by

    NawwalNawwuull
    Although many attorneys are familiar with narrative charting and SOAP(IE) charting. PIE charting is less commonly encountered. The initials in PIE represent the documentation of problems, interventions, and evaluation of nursing care. The goal of PIE charting as originally designed in 1984, was to streamline documentation. This was accomplished by eliminating the traditional care plan and incorporating an ongoing plan of care into the daily documention. 1. Key elements The PIE system of charting consist of flowsheets and the progress notes. Progress notes use nursing diagnosis as the problem. The problem stetment is labeled with “P” and numbered for easy reference. For example : Date Time Progress notes ( PIE Charting ) 1/6 13.00 P#1 risk for aspiration related to decreased level of consciousness. The intervention that the nurse carried out to alleviate the nursing diagnosis are recorded netx to an “I” and are numbered to correspond to the problem. The evaluation of the effectivientions is recorded next to an “E” and numbered. For example : Date Time Progress notes ( PIE Charting) 1/6 13.00 P#1 Risk for aspiration related to decreased level of consciousness I#1 Head of bed elevated to 45 degress for one hour after eating. 14.00 E#1 No evidence of aspiration. In this system of documentation an evaluation of each problems are addressed each day until the problem resolved. 2. Medifications of PIE Charting The PIE method is often modified in one or both of the following ways : A problem list is deloved to record the patient’s identifited problems An additional entry is made in the pie note assessment findngs are added to make the actually entry apie for example 6/11 2200 a#1 disoriented to time, place and person.calling for her husband to help her get up for breakfast 1#1 reoriented patient to use call bel assitace call be placed within reach 2300 e#1 patient continue to be disoriuented.has not used call bell.calls out for her husband Advantage and disadvantage of pie charting The major advantage pie charting is thaht its format encourages the use of the nursing process by structing the progress note to include nursing diagnose,interventions and evaluation .the sytem also promotes the systematic evalution of each identifited problem once every shift The primary disadvantage of pie charting is that the planning step of the nursing process is not documented. Pie charting skips from the problem to the intervensions that we carried out.althought experienced nurses can make the leap from nursing diagnosis to intervension without documenting planning. Novice nurses often have difficulty permorming without a plan of care.staff nurses usually do not have time to review pages of progress notes to determine which approaches have been used to resolve nursing diagnoses. They often rely on change-of-shift reports to determine the important needs of the patient, as knowledgeable attorneys discover when they question nurses in depositions. Meskipun banyak pengacara yang akrab dengan narasi charting dan SOAP ( IE ) charting . PIE charting kurang umum ditemui . Inisial di PIE merupakan dokumentasi masalah , intervensi , dan evaluasi asuhan keperawatan . Tujuan dari PIE charting sebagai awalnya dirancang pada tahun 1984 , adalah untuk merampingkan dokumentasi. Hal ini dilakukan dengan menghilangkan rencana perawatan tradisional dan menggabungkan rencana perawatan berkelanjutan ke dalam dokumentasi sehari-hari. 1 . elemen-elemen kunci Sistem PIE charting terdiri dari flowsheets dan catatan perkembangan . Catatan perkembangan menggunakan diagnosis keperawatan sebagai masalah . Masalah stetment dilabeli dengan " P " dan dinomori untuk referensi mudah . Sebagai contoh: Tanggal Waktu Kemajuan catatan ( PIE Charting ) 1/6 13.00 P # 1 resiko aspirasi berhubungan dengan penurunan tingkat kesadaran . Intervensi yang dilakukan perawat untuk mengurangi diagnosis keperawatan dicatat netx ke " I " dan nomor sesuai

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    of 4

    iyer, P. 2001. Nursing malpractice. USA: ISBN.

    Although many attorneys are familiar with narrative harting an! S"AP#I$% harting.
    PI$ harting is less ommonly enountere!. &he initials in PI$ re'resent the
    !oumentation of 'ro(lems, interventions, an! evaluation of nursing are. &he goal
    of PI$ harting as originally !esigne! in 1)*+, was to streamline !oumentation.
    &his was aom'lishe! (y eliminating the tra!itional are 'lan an! inor'orating an
    ongoing 'lan of are into the !aily !oumention.
    1. ,ey elements
    &he PI$ system of harting onsist of -owsheets an! the 'rogress notes.
    Progress notes use nursing !iagnosis as the 'ro(lem. &he 'ro(lem stetment
    is la(ele! with .P/ an! num(ere! for easy referene. 0or e1am'le :
    2ate &ime Progress notes # PI$ 3harting %
    145 16.00 P71 ris8 for as'iration relate! to !erease! level of
    onsiousness.
    &he intervention that the nurse arrie! out to alleviate the nursing !iagnosis
    are reor!e! net1 to an .I/ an! are num(ere! to orres'on! to the 'ro(lem.
    &he evaluation of the e9etivientions is reor!e! ne1t to an .$/ an!
    num(ere!. 0or e1am'le :
    2ate &ime Progress notes # PI$ 3harting%
    145 16.00 P71 :is8 for as'iration relate! to !erease! level of
    onsiousness
    I71 ;ea! of (e! elevate! to +< !egress for one hour after
    eating.
    1+.00 $71 No evi!ene of as'iration.
    In this system of !oumentation an evaluation of eah 'ro(lems are
    a!!resse! eah !ay until the 'ro(lem resolve!.
    2. =e!i>ations of PI$ 3harting
    &he PI$ metho! is often mo!i>e! in one or (oth of the following ways :
    A 'ro(lem list is !elove! to reor! the 'atient?s i!enti>te! 'ro(lems
    An a!!itional entry is ma!e in the 'ie note assessment >n!ngs are a!!e! to
    ma8e the atually entry a'ie for e1am'le
    5411 2200 a71 !isoriente! to time, 'lae an! 'erson.alling for her hus(an!
    to hel' her get u' for (rea8fast
    171 reoriente! 'atient to use all (el assitae all (e 'lae! within reah
    2600 e71 'atient ontinue to (e !isoriuente!.has not use! all (ell.alls out
    for her hus(an!
    A!vantage an! !isa!vantage of 'ie harting
    &he ma@or a!vantage 'ie harting is thaht its format enourages the use of
    the nursing 'roess (y struting the 'rogress note to inlu!e nursing
    !iagnose,interventions an! evaluation .the sytem also 'romotes the
    systemati evalution of eah i!enti>te! 'ro(lem one every shift
    &he 'rimary !isa!vantage of 'ie harting is that the 'lanning ste' of the
    nursing 'roess is not !oumente!. Pie harting s8i's from the 'ro(lem to
    the intervensions that we arrie! out.althought e1'eriene! nurses an ma8e
    the lea' from nursing !iagnosis to intervension without !oumenting
    'lanning. Novie nurses often have !iAulty 'ermorming without a 'lan of
    are.sta9 nurses usually !o not have time to review 'ages of 'rogress notes
    to !etermine whih a''roahes have (een use! to resolve nursing !iagnoses.
    &hey often rely on hangeBofBshift re'orts to !etermine the im'ortant nee!s
    of the 'atient, as 8nowle!gea(le attorneys !isover when they Cuestion
    nurses in !e'ositions.
    =es8i'un (anya8 'engaara yang a8ra( !engan narasi harting !an S"AP # I$ %
    harting . PI$ harting 8urang umum !itemui . Inisial !i PI$ meru'a8an !o8umentasi
    masalah , intervensi , !an evaluasi asuhan 8e'erawatan . &u@uan !ari PI$ harting
    se(agai awalnya !iranang 'a!a tahun 1)*+ , a!alah untu8 meram'ing8an
    !o8umentasi. ;al ini !ila8u8an !engan menghilang8an renana 'erawatan
    tra!isional !an mengga(ung8an renana 'erawatan (er8elan@utan 8e !alam
    !o8umentasi sehariBhari.
    1 . elemenBelemen 8uni
    Sistem PI$ harting ter!iri !ari -owsheets !an atatan 'er8em(angan . 3atatan
    'er8em(angan mengguna8an !iagnosis 8e'erawatan se(agai masalah . =asalah
    stetment !ila(eli !engan D P D !an !inomori untu8 referensi mu!ah . Se(agai
    ontoh:
    &anggal Ea8tu ,ema@uan atatan # PI$ 3harting %
    145 16.00 P 7 1 resi8o as'irasi (erhu(ungan !engan 'enurunan
    ting8at 8esa!aran .
    Intervensi yang !ila8u8an 'erawat untu8 mengurangi !iagnosis 8e'erawatan !iatat
    net1 8e D I D !an nomor sesuai !engan masalah. $valuasi e9etivientions !iatat
    se(elah D $ D !an (ernomor. Se(agai ontoh:
    &anggal Ea8tu ,ema@uan atatan # PI$ 3harting %
    145 16.00 P 7 1 :isi8o as'irasi (erhu(ungan !engan 'enurunan
    ting8at 8esa!aran
    I 7 1 ,e'ala ti!ur !iang8at 8e +< !egress
    selama satu @am setelah ma8an.
    1+.00 $ 7 1 &i!a8 a!a (u8ti as'irasi .
    2alam sistem ini !o8umentasi8an setia' evaluasi masalah yang !itangani setia'
    hari sam'ai masalah teratasi .
    2 . =e!i>ations PI$ 3harting
    =eto!e PI$ sering !imo!i>8asi !alam satu atau 8e!ua ara (eri8ut :
    2aftar masalah a!alah !elove! untu8 mere8am masalah i!enti>te! 'asien
    $ntri tam(ahan !i(uat !alam 'ie atatan >n!ngs 'enilaian yang !itam(ah8an untu8
    mem(uat a'ie se(enarnya masu8 misalnya
    5411 22.00 P7 1 (ingung 8e wa8tu, tem'at !an 'erson.alling (agi
    suaminya untu8 mem(antunya (angun untu8 sara'an
    I 7 1 'asien !iorientasi8an untu8 mengguna8an
    'anggilan (el assitae 'anggilan !item'at8an !alam @ang8auan
    2600 e 7 1 'asien terus men@a!i !isoriuente!.has ti!a8 !iguna8an (ell.alls
    'anggilan 8eluar untu8 suaminya
    ,euntungan !an 8erugian !ari 'ie harting
    ,euntungan utama 'ie harting yang thaht format men!orong 'enggunaan 'roses
    8e'erawatan !engan nyusun atatan 8ema@uan untu8 memasu88an !iagnosa
    8e'erawatan , intervensi !an evaluasi . Sytem @uga mem'romosi8an evalution
    sistematis setia' masalah i!enti>te! se8ali setia' 'ergeseran
    ,elemahan utama !ari harting 'ie (ahwa lang8ah 'erenanaan 'roses
    8e'erawatan ti!a8 !i!o8umentasi8an . Pie harting melom'at !ari masalah 8e
    intervensions (ahwa 8ita mem(awa 'erawat (er'engalaman out.althought !a'at
    mem(uat lom'atan !ari !iagnosis 8e'erawatan untu8 intervensi tan'a
    men!o8umentasi8an 'erenanaan . Perawat 'emula sering mengalami 8esulitan
    'ermorming tan'a renana are.sta9 'erawat (iasanya ti!a8 memili8i wa8tu untu8
    menin@au halaman atatan 8ema@uan untu8 menentu8an 'en!e8atan telah
    !iguna8an untu8 menyelesai8an !iagnosa 8e'erawatan . =ere8a sering
    mengan!al8an la'oran 'eru(ahanB 'eru(ahan untu8 menentu8an 8e(utuhan
    'enting 'asien , se(agai 'engaara (er'engetahuan menemu8an 8eti8a mere8a
    mem'ertanya8an 'erawat !i !e'osisi .

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