A nurse is using the focus charting method to document the progress notes of a client who has anxiety.

The nurse needs to write an evaluation entry in the focus charting method.

Which of the following is an example of an evaluation entry in the focus charting method?

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%.

“I feel more calm and relaxed after practicing the breathing exercises.”

This is an example of an evaluation entry in the focus charting method because it describes the client’s response to the nursing intervention of teaching relaxation techniques.Evaluation entries reflect theevaluation phaseof the nursing process and show whether the client’s goals and outcomes have been met or not.

Choice A is wrong because it is an example of an action entry, not an evaluation entry.Action entries reflect theplanning and implementation phaseof the nursing process and include immediate and future nursing actions.

Choice B is wrong because it is an example of a data entry, not an evaluation entry.Data entries reflect theassessment phaseof the nursing process and include subjective and objective information about the client’s health status.

Choice C is wrong because it is an example of a focus, not an evaluation entry.A focus is a key word or phrase that identifies the client’s concern, problem, or strength.It can be derived from a nursing diagnosis, a sign or symptom, an acute change in condition, a significant event, or a standard of care.

Choice E is wrong because it is an example of an action entry, not an evaluation entry.Action entries reflect theplanning and implementation phaseof the nursing process and include immediate and future nursing actions.

Focus charting is a method for organizing health information in the client’s record using nursing terminology to describe the client’s health status and nursing actions.

It uses three columns: date and hour, focus, and progress notes.The progress notes are organized into data, action, and response (DAR).

Normal ranges for vital signs are:.

• Temperature: 36.5°C to 37.5°C (97.7°F to 99.5°F).

• Pulse: 60 to 100 beats per minute.

• Respirations: 12 to 20 breaths per minute.

• Blood pressure: 120/80 mmHg (systolic/diastolic).