A PIE note records nursing care in three parts: the Problem, numbered and often written as a nursing diagnosis, the Interventions for it, and the Evaluation of how the patient responded. The full assessment sits on a flow sheet. Copy the free template, see a post-op pain example and an older adult with fall risk and constipation, and check what goes in each part.
Blank PIE note template
FreePIE NOTE Patient: [Full name] Date of birth: [Date] Unit, room, and bed: [Location] Date and shift: [Date, and day, evening, or night shift with its hours] Reason for stay: [Admitting diagnosis or procedure, and hospital, rehab, or post-op day] Allergies: [Drug, food, and latex allergies with the reaction, or none known] Nurse: [Name, credentials] DAILY ASSESSMENT FLOW SHEET Shift assessment: [Time done, and where on the flow sheet it is recorded] Outside your unit's norms: [Each finding by system, or none] Scores: [Pain, sedation, fall risk, pressure injury risk, or others your flow sheet uses, with each tool named] Problem link: [For each finding outside norms, the problem number it belongs to, a new problem opened, or why none is needed] PROBLEM LIST Active: [P#, label, and the date and shift each was opened] Resolved: [P#, label, and the date and time resolved; resolved numbers are not reused] P#[Number]: PROBLEM Problem statement: [Nursing diagnosis or problem, related to its cause, as shown by the signs; for a risk problem, the risk factors] Opened: [Date, shift, and nurse, or carried from the last shift] Goal: [A measurable outcome, set with the patient where possible, and when it will be checked] IP#[Number]: INTERVENTIONS Actions: [Each nursing action with its time] Medications: [Drug, dose, route, time, and the order's reason, such as a pain score range] Teaching: [What was taught, to whom, and how understanding was checked] Notified: [Name, role, time, what you reported, and the reply or new orders] EP#[Number]: EVALUATION Time: [Time of each evaluation] Response: [What changed, measured the same way as in the problem statement] Goal: [Met, partly met, or not met] Problem status: [Continues, revised with the new goal, or resolved with the evidence] Repeat the P, IP, and EP blocks for each active problem. Evaluate every active problem at least once each shift. HANDOVER Carried to the next shift: [Each open problem number, with what is due and when] Watch for: [Findings that should open a new problem or lead to a call] Signed: [Nurse name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Surgical unit, post-op day 1, day shift 07:00 to 19:00
52-year-old woman, post-op day 1 after a total abdominal hysterectomy through a low transverse incision, for large fibroids. No known drug allergies. Shift assessment at 07:30 on the daily assessment flow sheet. Outside the unit’s norms: pain 7/10 at rest on the 0 to 10 numeric scale and 9/10 on coughing; abdomen soft and mildly distended, bowel sounds hypoactive, no flatus yet; urinary catheter removed at 06:00, not yet voided. T 37.6 °C (99.7 °F), HR 96, BP 142/84, RR 16, SpO2 96% on room air. POSS 1. Dressing dry and intact. The surgical team stopped her IV hydromorphone PCA at 06:00 and ordered oral analgesia. Active problems: P#1 Acute pain, opened at 21:00 on the day of surgery. No new problem opened: voiding is tracked on the flow sheet, with a first void due by 12:00.
Acute pain related to the abdominal incision and the switch from IV to oral analgesia, as shown by pain 7/10 at rest and 9/10 on coughing, guarding, and grimacing. “It’s a deep burn across the cut whenever I move.” Opened by the evening nurse on the day of surgery; carried from the night shift. Goal for today, set with her: pain 4/10 or lower at rest by 10:00, and able to walk the hallway 3 times and cough with a pillow by 19:00.
Orders: acetaminophen 1,000 mg by mouth every 6 hours, scheduled; ibuprofen 400 mg by mouth every 6 hours with food, scheduled; oxycodone by mouth every 4 hours as needed, 5 mg for pain 4 to 6 or 10 mg for pain 7 to 10. 07:40: oxycodone 10 mg by mouth for pain 7/10, after checking RR 16 and POSS 1. 07:50: taught her to hold a pillow firmly over the incision to cough, move, and get up, and to roll onto her side before sitting up; she showed both back. 08:00: ibuprofen 400 mg with breakfast. 10:15: walked 40 m (130 feet) in the hallway with a nurse beside her. 11:50: oxycodone 5 mg for pain 5/10, before her second walk. 12:00: acetaminophen 1,000 mg. 14:00: ibuprofen 400 mg. 16:05: oxycodone 5 mg for pain 5/10. 18:00: acetaminophen 1,000 mg. Each dose signed on the MAR.
08:40, 60 minutes after the first oxycodone dose: pain 4/10 at rest, 6/10 coughing with the pillow. RR 14, POSS 1. Rest goal met by 10:00. 10:15: pain 6/10 while walking, 4/10 back in bed. 12:50: pain 3/10 at rest and 4/10 walking; second walk done. 17:05: pain 3/10 at rest. Third walk at 17:30, 60 m (200 feet). Coughing and deep breathing hourly while awake, with the pillow. No nausea. “I can actually move now.” Goal met. P#1 continues, revised for post-op day 2: pain 3/10 or lower at rest on oral medication, and 4 walks.
19:00, to the night nurse. P#1 Acute pain continues: last oxycodone 5 mg at 16:05, next available from 20:05; ibuprofen due at 20:00 and acetaminophen at 24:00. Night goal: pain 4/10 or lower, enough to sleep. From the flow sheet: voided 350 mL at 11:40 and 400 mL at 16:30, so no urinary problem opened; passing flatus since 14:00. No resolved problems. Signed at 19:10.
Inpatient rehabilitation unit, rehab day 5, day shift 07:00 to 15:00
81-year-old woman, rehab day 5 after a hemiarthroplasty 12 days ago for a right hip fracture from a fall at home. Lives alone; walked without an aid before the fall. Shift assessment at 07:30 on the daily assessment flow sheet. Alert and oriented to person, place, and time. Outside norms: right hip pain 3/10 at rest and 5/10 walking; weak right leg; walks with a 2-wheeled walker and standby assist; got up alone once last night to use the toilet, by the night report; last bowel movement 5 days ago; abdomen soft and mildly distended, bowel sounds present in all 4 quadrants. Morse Fall Scale 80: a fall before admission, more than one diagnosis, a walker, a weak gait, and forgetting her limits at night; no IV. Active problems: P#1 Risk for adult falls, opened on admission to rehab; P#2 Constipation, opened yesterday on the day shift.
Risk for adult falls. Risk factors: the fall that broke her hip, surgery 12 days ago, a weak right leg, a walker she is still learning, toileting at night, and standing up without calling for help. Opened by the admitting nurse on rehab day 1; carried from the night shift. Goal: no falls, and she calls before standing every time; checked each shift.
07:20: bed alarm on from the night, bed low and locked. 07:45: lying and standing blood pressure before her first stand: lying 136/78, HR 74; standing at 1 minute 128/76, HR 82; at 3 minutes 126/74, HR 84. Non-slip socks on, walker beside the bed. Toilet offered at 08:30, 10:30, 12:30, and 14:30. 09:00: taught her why to call before standing, and checked with teach-back. 11:10: found her standing alone from the chair to reach her phone on the windowsill; steadied her; no fall and no injury. Moved her phone, glasses, and water to the table on her left. Chair alarm pad on from 11:20. Charge nurse told at 11:25; near miss logged in the safety reporting system. 13:00: physiotherapy, walked 40 m (130 feet) with the walker and standby assist.
14:40: no falls this shift. No drop in blood pressure on standing. She called before standing 4 of 5 times; the one time she didn’t was at 11:10, before the chair alarm. At 14:30 she gave the rule back in her own words: “Bell first, then the walker, then up.” Goal partly met. P#1 continues: bed alarm at night, toilet at 22:00, 02:00, and on waking, and the chair alarm whenever she sits alone.
Constipation related to oxycodone, less walking than usual, and low fluid intake, as shown by no bowel movement for 4 days, straining without result, and a mildly distended abdomen. She takes oxycodone 2.5 mg by mouth before physiotherapy and at bedtime. At home she goes every morning after coffee. Opened yesterday at 10:00. Goal: a soft bowel movement without straining within 48 hours.
Orders since yesterday: polyethylene glycol 3350 17 g in 250 mL of fluid by mouth daily, and senna 17.2 mg by mouth at bedtime, given last night at 21:00. 07:30: warm coffee with breakfast, as she has at home. 08:00: polyethylene glycol 17 g in 250 mL of juice. 08:30: walked to the toilet with the walker and standby assist; footstool under her feet, door closed, call bell in hand, nurse waiting just outside. Fluids encouraged: 1,100 mL by 14:00, toward a goal of 1,500 mL by bedtime.
08:50: large soft bowel movement, Bristol type 4, with no straining or pain. 09:30: abdomen soft, not distended. “That’s a weight off.” Goal met. P#2 resolved at 09:30 and moved to the resolved list; the number is not reused. Bowel movements stay on the flow sheet while she takes oxycodone. Physician updated at 10:00: bowel regimen continues as ordered.
In PIE charting the full shift assessment goes on a flow sheet, not in the note. The note starts where the flow sheet turns up something that needs nursing care.
Avoid: A finding outside norms that leads nowhere. Link it to an open problem, open a new one, or say why it doesn’t need one.
A numbered problem, often a nursing diagnosis, that stays with the patient from shift to shift until it is resolved. The number is how every later entry finds it.
Avoid: A medical diagnosis as the problem. “Hysterectomy” is why she is on the unit; “acute pain” is what nursing care treats and can evaluate.
What you did for that problem, under the same number, so the actions and the problem stay together across shifts.
Avoid: Filing an action under the wrong number. A laxative written under IP#1, the fall risk problem, can’t be traced when someone reviews P#2.
How the patient responded, measured against the goal, and whether the problem stays open. Every active problem gets one each shift.
Avoid: “Continue plan” with no finding. Even when nothing changed, write what you checked: “EP#1: no falls, alarm on, continues.”
The running list of open and resolved problems, and what the next nurse needs for each one still open.
Avoid: Giving a resolved problem’s number to a new one. A new problem takes the next unused number, so older entries still point to the right problem.
Every open problem needs an EP each shift, even when nothing changed. Without one, the next nurse can’t tell whether the problem is still being worked on or was quietly dropped.
P#2 stays P#2 until it resolves, and its number is never handed to a new problem. Renumbering mid-stay breaks the trail, and yesterday’s IP#2 ends up pointing at the wrong problem.
PIE keeps the assessment on the flow sheet. Copying it under every problem makes long notes and two records that can disagree. Write only the findings that define the problem and the measure you’ll evaluate.
“Pain controlled” can’t be marked met or not met. “Pain 4/10 or lower at rest by 10:00” can, and it tells the evaluation what to check and when.
PIE has no heading for things that aren’t problems, such as a family meeting or a transfer. Record them where your policy says, often a separate timed entry, rather than leaving them out.
Dictate after each round, problem by problem. Vero Scribe writes the problem, interventions, and evaluation for each number in your template, keeping the times, doses, and pain scores you said. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
PIE charting is a problem-oriented way of writing nursing notes, developed in the 1980s: Problem, Intervention, Evaluation. Each problem gets a number, often as a nursing diagnosis, and keeps it until it is resolved. Interventions and evaluations carry the same number, so IP#2 and EP#2 belong to P#2. The full assessment goes on a daily flow sheet, and the numbered problems take the place of a separate written care plan.
Record the shift assessment on the flow sheet first. For each finding that needs nursing care, open a problem with the next unused number, a nursing diagnosis or plain problem statement, and a measurable goal. Under IP, write what you did, with times and doses. Under EP, record the response with the same measure, whether the goal was met, and whether the problem continues, changes, or is resolved. For example: “P#1: Acute pain related to the incision, pain 7/10 at rest. IP#1: oxycodone 10 mg by mouth at 07:40; taught pillow splinting. EP#1: 08:40, pain 4/10 at rest; continues.”
DAR, or focus charting, can start from any focus, including teaching or an admission, and writes the findings into each entry under Data; its entries aren’t numbered. SOAP and SOAPIE write subjective and objective findings and an assessment into each entry. PIE leaves the findings on the flow sheet and writes only the numbered problem, what you did, and how it worked, so entries are shorter. Narrative notes tell the shift in time order, with no headings.
Where problems last several shifts and nurses already use nursing diagnoses: medical-surgical units, rehabilitation, and long-term care. It lets anyone follow one problem from the day it opened to the day it resolved. It fits less well where the picture changes by the minute, as in critical care, where flow sheets carry most of the record, or for one-off events with no ongoing problem.
Yes. Copy it, or download it as a Word or text file. No account needed.
System-by-system nursing assessment with pressure injury and fall risk, lines and drains, and escalation.
The shift note: assessment, timed vital signs and interventions, the response, provider calls, teaching, and the plan for the next shift.
Assessment data, nursing diagnosis, SMART outcomes, interventions with rationale, and evaluation, one diagnosis at a time.
The bedside handoff in I-PASS order: severity, systems, lines, meds due, pending labs, risks, to-dos, and read-back.
Focus charting in four parts: the focus, the data behind it, nursing actions, and the timed patient response.
PIE and DAR entries, SBAR calls, and nursing notes, drafted for your review.
Nursing note examples in several formats, side by side.
Where each dose named in an IP entry is signed.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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