PIE 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]