How to write PIE notes

Wondering about PIE notes and the PIE charting nursing notes format? This article contains helpful information on PIE notes, including PIE notes examples and actionable tips on using the PIE documentation format.

Summary for clinicians

• PIE notes provide a structured three-part documentation system (problem section, intervention section, evaluation section) that streamlines clinical record-keeping and improves patient care continuity.
• The problem section captures client concerns and symptoms comprehensively, the intervention section outlines specific treatment approaches, and the evaluation section tracks client responses and treatment effectiveness.
• The PIE charting nursing notes format eliminates unnecessary documentation while ensuring all critical care phases are documented, making it ideal for busy clinical environments.
• PIE notes support quality patient care by providing clear, linear documentation that facilitates quick information retrieval and effective treatment planning.

What are PIE notes?

PIE notes are a form of clinical documentation used by therapists, nurse practitioners, and other clinicians.

PIE is an acronym for problem, intervention, and evaluation. These three components are essential to PIE charting nursing notes and allow for direct problem-solving in text form. This format provides a systems approach for clinicians to document patient encounters succinctly. 

The primary goals of PIE notes include prompt identification, strategy, and evaluation of the client's response.

With PIE notes, the plan's summarized elements are represented in a linear form. The method is helpful for locating important information quickly, as PIE documentation is simplistic and clear. 

Understanding the PIE format

As mentioned above, PIE notes stand for:

P=Problem 

The problem section should include the client's concerns and symptoms.

I=Intervention

The intervention section should have the practices or approaches that will be used to address the client's problem, which is reflected in the P section.

E=Evaluation

The evaluation section should have the client's response to the interventions presented in the I section. The evaluation section is unique in that it allows the professional to track their intervention's progress over time and determine if the intervention is meeting the client's needs.

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Problem section examples

This section mainly identifies the client's concerns and/or symptoms. The importance of this section is that the therapist conveys the client's needs, however complex and intricate they may be. 

For example, for a therapist helping a client with anxiety, here is an example of PIE notes of the problem section:

The client presents for therapy for anxiety, with an inability to focus with feelings of agitation. The client reports that she has felt this way for over eight months, but the inability to focus and agitation have increased over the last two weeks. The client states she sought professional help per the recommendation of her mother and husband. Per the client, they both have noticed a change in her behavior. The client denies suicidal ideation and denies the urge to harm others. The client reports that when she experiences anxiety, it is as if she is in a tunnel and unable to process information that is being presented.

Here is another example of the problem section in PIE documentation for a clinician working with a couple who are experiencing communication difficulties:

The couple presents for therapy for communication difficulty, with an inability to communicate effectively on a daily basis. After the husband lost his job a month ago, communication has deteriorated to the point where minor disagreements turn into huge arguments. The wife feels the communication issues are due to the new household stressors caused by the financial strain of the husband losing his job. The couple states they want to improve their communication without raising their voices at each other. The couple reports that they want to remain married and want to repair and build a stronger marital bond. They are requesting advice on practical problem-solving skills and strategies.

Intervention section examples

The intervention section allows the clinician to process the information obtained in the problem section and create an action plan in which the therapist aims to alleviate clients’ problems through proper techniques and strategies. 

For the client with anxiety,here is a PIE notes example of an intervention section:

After gathering all the client's information regarding anxiety, a recommendation for cognitive behavioral therapy was given to meet the needs of the client and alleviate or decrease her levels of stress and agitation. Cognitive behavioral therapy will teach the client different ways of thinking, responding, and acting in situations to help her feel less anxious/agitated. The goal is to provide the client with tools and strategies to use to diminish her anxiety as it peaks, allowing her the ability to self-regulate her emotions in real time, thereby decreasing her agitation.

Here is another example of the intervention section of PIE documentation for a couple dealing with communication difficulties:

After gathering all the couple's information regarding their inability to communicate, a recommendation for psychotherapy and conflict resolution strategies was given. This form of communication will assist the couple in processing their feelings while respecting the partner's feelings during exchanges. The goal is to provide the clients with tools and strategies to converse without big emotions getting in the way, allowing for true, authentic communication to occur.

Evaluation section examples

The evaluation section focuses on whether the plan, techniques, or recommendations met the primary goal or whether the intervention prompted a response from the client. 

This section can list any feedback or reactions to the intervention between the client and the proposed strategy. 

The clinician uses this section to reflect on whether the intervention prompted the planned outcome or if other adjustments need to be made regarding the initial intervention. 

In the evaluation section, the therapist determines the next step regarding the care plan. 

For example, here is a PIE notes example of the evaluation section for a client with anxiety:

The client went to cognitive behavioral therapy, where she discussed her anxiety and physiological responses when she is in an episode of anxiety. The client discussed her anxiety triggers, as well as feelings of deep anxiety regarding her recently starting graduate school. We identified coping strategies and supportive people in her life who can help her in her times of anxiety. Strategies to manage her anxiety included cognitive restructuring, practicing mindfulness, behavior activation, and stress-reduction techniques. The client is willing to use these strategies and will allow her support system to help her when needed.

Here is another example of PIE documentation for the evaluation section for a couple dealing with communication difficulties:

The couple went to psychotherapy, with both parties discussing their frustration with the other partner when discussing everyday items. Both parties discussed their internal emotional reactions and how their feelings contribute to outbursts. Conflict resolution strategies recommended included identifying each other's needs, listening and speaking respectfully, brainstorming and creating solutions, and appreciating common ground. The couple is willing to use these strategies and will allow each other the space to implement problem-solving strategies when needed.

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Benefits of PIE notes format in clinical practice

PIE charting nursing notes allow clinicians to write notes promptly so that they are available for other clients or other professional commitments. 

These notes get right to the point, removing all the fluff other documentation formats contain. 

One significant aspect of PIE charting nursing notes is that clinicians can customize the sections to meet their needs. For example, the evaluation section can have additional recommendations, or the intervention section can have a more detailed plan.

Modern healthcare professionals, including those using psychiatric nurse practitioner notes software, may find that the PIE format nursing notes approach streamlines documentation while maintaining clinical accuracy. 

Whether you're creating psychiatric nurse practitioner notes or working with specialized psychiatric nurse practitioner software, the PIE method adapts well to digital platforms and electronic health records.

Nurse practitioners depend on clinical documentation to provide quality care. The PIE notes format allows professionals to write straightforwardly, hitting all the critical phases of care while ensuring comprehensive patient documentation.

Conclusion

PIE notes offer healthcare professionals a structured, efficient approach to clinical documentation. 

By focusing on the problem, intervention, and evaluation components, clinicians can create thorough yet concise records that support quality patient care. 

Due to the flexibility of PIE charting, nursing professionals find it to be an invaluable tool across various healthcare settings, from private practice psychiatric nurse practitioners to hospital-based nursing staff.

Sources

• Clinical Documentation Standards for Healthcare Professionals. Journal of Healthcare Documentation, 2024.
• American Nurses Association. Nursing Documentation Guidelines and Best Practices. 2023.
• Healthcare Information and Management Systems Society (HIMSS). Electronic Health Records Documentation Standards. 2024.
• National Association of Social Workers. Clinical Documentation in Mental Health Settings. 2023.
• Joint Commission on Accreditation of Healthcare Organizations. Documentation Requirements for Patient Care. 2024.
• American Medical Association. Clinical Documentation Improvement Guidelines. 2023.
• Centers for Medicare & Medicaid Services. Documentation Guidelines for Healthcare Providers. 2024.

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