charting resting with eyes closed vs "asleep"

[smartnurse1982]

Anyone can give me the rationale for charting resting with eyes closed? In Ny where I went to school we just charted "Pt asleep." But in another part of the country they are saying its unprofessional. Which one is better to chart? Is there anything written evidence that supports one over the other?

[caliotter3]

I was taught on my first job to chart resting with eyes closed, etc. versus "asleep", because, I was told, you can not determine that the person is really asleep unless you disturb them and wake them up. I have also been told both ways to chart. The Everything method and the Minimal method. I prefer to do something in between. I used to read the notes of one nurse in home health, that wrote three books all over the form. I wondered how in the world she did everything she said she did on that nursing note and still have time to do all that copious charting. Something tells me she spent more time "charting" her novels than she did "providing" the nursing care she claimed.

[Boog'sCRRN246, RN]

I also learned to chart "resting with eyes closed" as you can't be entirely sure that the patient is actually asleep, but I don't know that I would call it unprofessional if a nurse charted "patient asleep".

[smartnurse1982]

I've seen nurses write 3 sentences for the whole 8 hours they were there. I thought every 2 hours minimal. In ltc I've seen charts that had not one nurses note for 6 months.

[caliotter3]

One of my present employers specifically requires "every two hours". Others have not been so specific, one just said don't bother repeating stuff in the narrative summary that you have charted in the check-off portion elsewhere on the form. As a minimum for a night shift where not much is happening, I chart beginning of shift, end of shift, something in the middle, and anything else of significance. I may chart every two hours that I checked the patient and they are "resting quietly with eyes closed, etc." For the other employers, I still put in my minimum which may or may not be their minimum. You are right, some don't do much charting. If the nursing supervisors let that kind of charting go, then that is a signal to the other nurses that three sentences are sufficient.

[Baloney Amputation, BSN, LPN, RN]

In ltc I've seen charts that had not one nurses note for 6 months.

Sometimes the LTC residents are completely at baseline and have no issues that arise for a good long time, sometimes years. It's a good thing when there's nothing to report in the chart.

[morte, LPN, LVN]

Sometimes the LTC residents are completely at baseline and have no issues that arise for a good long time, sometimes years. It's a good thing when there's nothing to report in the chart.

and there is the monthly summary, yes?

[clemmm78, RN]

I would never write that a patient was asleep based on my visual observation. I may state that someone had been asleep when I witnessed them waking, but otherwise, always "appears to be sleeping."

[meandragonbrett]

In bed with eyes closed.......all observation and not subjective

[SWS RN, ASN, RN]

Was taught-"in bed-eyes closed" respirations even and unlabored, or a variation on that theme.

Can't tell if the pt is sleeping or not. Yes, it is objective.

Also, the charting frequency depends on what the policy is for your floor and facility.

In PICU and ICU there were flow sheets for vs and observations. We charted by exception. So did not have to write out alot. The facility was adamant about this, as it always held up in court.

If you chart too much, it opens you to liability, as you could not possibly chart on every body system every two hours, so again, by exception.

Yes, in LTC there are monthly summeries and it is not necessary to chart on every patient every shift. In fact, it's not only not required it would be frowned upon. I was a DON in 2 facilities and did chart audits.

s

[JustEnuff2BDangerous, BSN, RN]

I was taught in nursing school to chart the obvious but not the assumed - If I walk into a room and a pt is napping, I usually write, "Pt resting supine/lateral R side/lateral L side with eyes closed. Respirations even and deep, no S/S of distress noted. Side rails up, call light in reach, will monitor." This covers all my bases - shows I checked on the pt and that they are safe in every sense of the word. It's pretty obvious they probably ARE asleep but that whole spiel says more about the pt than just "pt asleep". I was also taught not to write anything about "appears", an instructor told me you should never say anything "appears" to be something, either it is or it is not, but I think that was more of a personal professional preference to her.

Also, we do hourly charting between 7 am and 10 pm, meaning something has to be charted on the pt every hour, whether it's position, vital signs, potty trips, a narrative note, etc. It's a team effort and on days when I have 12 pts I rely very heavily on my LPN and CNA to help me stick to that, especially when I'm trying to get assessments done!

[caliotter3]

Use of the word "appears" is a no no, not just a personal preference of nurses. This statement, using the word "appears", can be taken apart, (like many statements), in court.