Format of Progress Notes (DAR)

Format of Progress Notes (DAR) ( 5 Questions)

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?



Correct Answer: C

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 the Problem, Intervention, and Evaluation 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%.




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