A nurse is using the PIE documentation system to document the progress notes of a client who has pneumonia.

The nurse needs to write an evaluation entry in the PIE documentation system.

Which of the following is an example of an evaluation entry in the PIE documentation system?

The client’s oxygen saturation level has improved from 88% to 95% after receiving oxygen therapy for 24 hours.

This is an example of an evaluation entry in the PIE documentation system because it describes the outcome of the intervention (oxygen therapy) for the problem (low oxygen saturation level) using objective data (percentage).

Other choices are wrong because:.

• Choice A: The client has been coughing less frequently and reports feeling less short of breath.

This is an example of an intervention entry because it describes the actions taken by the nurse to address the problem (coughing and shortness of breath).

• Choice B: The client has a productive cough with yellowish sputum and crackles in the lower lobes of both lungs.

This is an example of a problem entry because it identifies the signs and symptoms of the health condition (pneumonia).

• Choice D: The client will maintain a normal oxygen saturation level of at least 92% with supplemental oxygen as needed.

This is an example of a plan entry because it states the expected outcome or goal for the problem (low oxygen saturation level).

The PIE documentation system is a process-oriented system that uses the acronym PIE to document theProblem,Intervention, andEvaluation of the patient’s progress.It integrates care planning with progress notes and does not separate the patient from the environmental influences.The normal oxygen saturation level for healthy adults is between 95% and 100%.

Observed facial grimace and guarding of the abdomen.

This is an example of a data entry in the DAR format because it describes the objective and subjective information that the nurse collected from the client.Data entries can include vital signs, physical assessment findings, laboratory results, and client statements.

Choice A is wrong because it is an example of an action entry in the DAR format.Action entries describe the nursing interventions that the nurse performed to address the client’s problem or need.

For example, administering medication, providing education, or applying a dressing.

Choice B is wrong because it is an example of a response entry in the DAR format.Response entries describe the client’s reaction or outcome to the nursing interventions.

For example, reporting pain relief, expressing satisfaction, or showing improvement.

Choice D is wrong because it is also an example of an action entry in the DAR format.

It describes another nursing intervention that the nurse performed to help the client cope with pain.

The DAR format is a type of focus charting that helps nurses document problems identified in the client care plan.

It stands for data, action, and response.Some nurses may use the F-DAR format, which adds a focus component to provide a clearer context and prioritization of the client’s needs.The focus can be a nursing diagnosis, a change in condition, a symptom, or an event.