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?

[JustEnuff2BDangerous, BSN, RN]

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.

I wish they'd make that more widely known then, because I see it all the time!

[caliotter3]

I used "appears" myself because I always saw it used by others, until someone pointed out to me that it is wrong to use it because it indicates an opinion instead of a statement of fact.

[K.P.A.]

Anyone can give me the rationale for charting resting with eyes closed?

Tired eyes. I thought you were referring to the person doing the charting :-)

[Mike A. Fungin RN]

I have a checkbox for "Patient appears asleep." That's really all you can attest to without waking them up.

[NurseLoveJoy88, ASN, RN]

I work in AlF and all residents must have a weekly note whether they are baseline or not. Maybe I could be wrong but not charting on residents for up to 6 months doesnt seem right. (excuse my grammer/spelling Im typing on my phone)

[klone, MSN, RN]

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.

We chart by exception. Sometimes in a 12-hour shift on a healthy patient, I won't have any narrative written. I don't believe in charting for the sake of charting. I chart if I have something to say or there is a change in status.

[cherrybreeze, ADN, RN]

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.

I imagine it depends on where you work. I work on an inpatient surgical unit, and we chart by exception. The requirement is (at least) one focus note in 24 hours; so, if they had abdominal surgery, then sometime throughout the course of the day, there needs to be a note about the state of their abdomen. Many nurses, however, will still write an "eval" note at the end of their shift, even if nothing is out of the ordinary, and this is NOT CBE. Of course, anything that isn't an expected finding gets charted (being straight-cathed, a respiratory issue, etc).

Long story short, "3 sentences for the whole 8 hours they were there" would be too much, in a lot of cases. 3 sentences for the 12 hours I was there might be too much. If nothing unexpected happened, and a note was already written, I might not have to make a note at all. The assessment is charted separately (and that's another story...expected findings should just be a checkmark; ie, lungs clear is a check, not a "cl," but a lot of nurses write it out and don't have to). There is a fear, I think, of not charting enough, but if the patient's recovery/course of treatment is WNL, you don't need to spell it out, actually.

[systoly]

As others have said, state of sleep is difficult to determine by visual assessment, however, quality of respirations, facial expression, posture or positioning, etc. can be and are actually much more valuable.

[caliotter3]

The OP is referring to a home health extended care work situation. Each shift worked must have a minimum amount of charting to show that an assessment was done and that all elements of the plan of care were addressed during the shift. Usually hh agencies have a checklist style nursing note with an area for a narrative summary. Each nurse must chart to standard so that his/her note is a stand alone record of the care provided during that particular shift.

[LouisVRN, RN]

I agree without the majority of the other posters have said. It is impossible to determine if the patient is sleeping/sedated/in a coma by visual assessment alone. I always chart, "Pt lying in bed/Sitting in recliner, eyes closed, breathing unlabored, no apparent distress". We have a separate charting system for call bell within reach, side rails elevated and positioning.

At the hospital unit I work on we are required to document every four hours, but are supposed to round on our patients every two hours on night shift. In school I was told if you don't document it, you didn't do it, so I document a minimal assessment, of pain and IV every two hours.

[MikeyBSN]

I don't like writing that a person is "sleeping" or even "resting with eyes closed". Luckily, I work in the ED and most of my patients do not sleep. In the morning if I get endorsed patients I might wright "sleeping and arousable" or some other way to let someone know the patient is sleeping and not unresponsive. I have been endorsed "sleeping" and "drunk" patients before who decided not to wake up and then became ICU patients. How do we know that "sleeping" or "resting with eyes closed" is not really "bleeding in brain"?

[Otessa, BSN, RN]

I had never heard of charting "resting with eyes closed" until today and I have been an RN for over 18 years.

Is this regional?

otessa