Buckley-Womack C, Gidney B
Southern Illinois University School of Medicine, Department of Psychiatry, Springfield 62708.
J Neurosci Nurs. 1987 Oct;19(5):256-60. doi: 10.1097/01376517-198710000-00007.
In February 1986, the 43-bed neurology/neurosurgery unit at a midwestern medical center implemented the problem identification, intervention, and evaluation (PIE) method of documentation. This method incorporates the plan of care into the nursing progress notes, eliminating the need for a traditional care plan. Identified patient problems are documented on a problem list in the form of nursing diagnoses. These problems are evaluated each shift in the nursing progress notes. Routine interventions and assessments are documented on a comprehensive flow sheet. Since the inception of the PIE method, the quality of documentation on the unit has increased, while time spent on charting has decreased. Professional accountability and credibility are evident as nurses document nursing interventions and evaluate their effectiveness.
1986年2月，中西部一家医疗中心拥有43张床位的神经科/神经外科病房实施了问题识别、干预和评估（PIE）记录方法。这种方法将护理计划纳入护理病程记录，不再需要传统的护理计划。确定的患者问题以护理诊断的形式记录在问题清单上。这些问题在每次护理班次的病程记录中进行评估。常规干预措施和评估记录在一份综合流程表上。自PIE方法实施以来，该病房的记录质量有所提高，而用于记录的时间减少了。当护士记录护理干预措施并评估其效果时，专业责任感和可信度显而易见。
