charting

  1. We are always told not to chart that the patient is sleeping. however, what if I chart, "pt was sleeping, but arouses easily from sleep." that should be ok right, b/c that would show that they aren't dead because they woke up? i charted that in part of my notes, and left the hospital, then thought, hmmm, maybe shouldn't have done that. what are everyone's opinions?
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  2. 23 Comments

  3. by   WAstudent
    I think it's okay to chart about patients sleeping or resting. We are encouraged to. Especially if the patient has had a hard day or night for whatever reason. I always include a descriptive, like comfortably, soundly. It is also appropriate to chart if the patient is having a hard time sleeping or waking up a lot. The more descriptive and consice the better. How many times is the patient waking up? I also appreciate it when I see it charted prior to coming on shift, because then I have a better overall idea on how the patient is doing and tolerating treatment.
  4. by   girlfromtx
    thanks for answering. i feel better . i could just see myself getting sued one day over that one little line lol.
  5. by   elkpark
    So, how many times a night are you waking patients up just to verify that they "arouse easily from sleep"? How would you like it if someone did that to you? There are plenty of ways to verify (and document) that the patient is still alive besides waking them up! (Plus, in my state, it's part of the state Patient Bill of Rights that people have the right (enforceable by the state surveyors) not to be awakened at night unless it's really necessary.) It's not that much more trouble to write "eyes closed, resp. even and unlabored," or something similar, and that's something you can observe without disturbing someone.

    (When I was working nights, my favorite patients were always the snorers -- you can tell from the doorway (if not the nursing station) whether they're asleep or not, and it's so easy to document! :chuckle)
  6. by   girlfromtx
    I'm not waking them up all night lol. just right before I leave, to make sure they are alive and well before I pass them on. I guess living in such a litigious (very much so) area of the country, we are told to NEVER chart that they are sleeping. I agree with you guys, that it is a little crazy, but I was told from more than one professor to wake them up, b/c of documented cases where nurses thought they were sleeping but in actuality had been dead for hours etc, though I don't think it is that hard to tell if they are sleeping or dead lol.
  7. by   elkpark
    You are right; I, too, was taught many years ago (and have been reminded many times since then) not to chart that someone is "sleeping" because, technically, we don't really know if they're sleeping -- they could just be lying there with their eyes closed, playing possum. However, what we do know (and what I have always charted) is that they are lying quietly in bed, eyes closed, resp. even and unlabored (or deep and even, or whatever they are). That way, we are charting objective observations, not our subjective conclusions about those observations.

    What I have never been told is to wake someone up to make sure s/he is still alive ... As you noted, we nurses have other ways to verify that someone is alive -- how hard is it to stand quietly next to the bed briefly and verify that someone is breathing? And, if they're breathing, they ain't dead.

    When I was a psych surveyor for my state, I did investigate one death on a psych unit (death investigations were a routine part of our job) where it turned out that the person had actually died around 12 or 1 AM, and staff faithfully made "safety checks" every 30 mins all night, per unit policy, without noticing the person wasn't breathing anymore -- no one noticed the person was dead until AM vital signs the following morning (you should have seen the note left on the chart by the doc who responded to the code call! ) So, yes, that actually does happen occasionally. Eeeewwwwww!!
  8. by   girlfromtx
    what you are saying actually makes sense. go figure lol.
    Last edit by girlfromtx on Oct 25, '05
  9. by   elkpark
    (Well, I do try to make sense as often as possible ... :chuckle )
  10. by   nursedawn67
    I have always been taught you would chart "resting quietly in bed with eyes closed" and if they happened to be woke up for something then would add "arouses easily to verbal stimuli" or "arouses easily to physical stimuli". Because technically even if all signs point to it you cannot say they are sleeping. We have all been known to lay very quietly with eyes closed and technically not be sleeping.
  11. by   klone
    Thankfully, we chart by exception!
  12. by   txspadequeenRN
    I always put. Resident sleeping, eyes closed breathing even and unlabored. No s/s distress noted. Resident arouses easily with verbal and tactile stimulation. Plus, I always mention if they are snoring. I think you are alright with your note...


    Quote from girlfromtx
    We are always told not to chart that the patient is sleeping. however, what if I chart, "pt was sleeping, but arouses easily from sleep." that should be ok right, b/c that would show that they aren't dead because they woke up? i charted that in part of my notes, and left the hospital, then thought, hmmm, maybe shouldn't have done that. what are everyone's opinions?
  13. by   student4ever
    I always chart "resting quietly, in no apparent distress," and then include a note about the breathing, such as "resps even and unlabored, normal, shallow," whatever they might be. I also touch them gently on the hand and chart whether their skin felt warm, dry, cold, sweaty, etc. That shows that I have truly checked on them, made sure they were comfortable, etc. The gentle touch on the hand isn't usually enough to wake a patient up if they're sleeping, and if they're just resting, gives them a chance to ask me for something they might need.
  14. by   Tweety
    I put "eyes closed, respirations unlabored", or "sleeping, respirationis even and unlabored" or "respirations WNL" .............the point is "sleeping" could be mistaken for comatose or dead and you want a jury to know you took the time to watch them breathe. At least that was how I learned years ago.

    But I'm sure "sleeping" implies that they are breathing. But if you're not actually arousing them, then don't chart that you are.

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