How To Document Sleeping On Night Shift

How To Document Sleeping On Night Shift

I usually chart "Pt appears to be sleeping, no respiratory distress noted" is this sufficient for charting that a pt is asleep? I heard that we should chart pt IS sleeping as it becomes a legality issue. What do other RN's chart when a pt is sleeping...thanks for the tips!

What Members Are Saying (AI-Generated Summary)

Members are discussing the appropriate way to document a patient's status in medical charts, specifically focusing on whether to use the term "sleeping" or "resting with eyes closed" to avoid potential legal issues. Some users suggest using more detailed descriptions to cover themselves, while others express frustration at the need to be cautious in their documentation. The conversation also touches on the use of the term "appears to be sleeping" and the potential for lawyers to scrutinize charting language.

75 Answers

Specializes in Oncology/BMT.

I document on the patient at least every two hours on night shift... Typically, I chart my assessment at 2000... Then the rest, if all goes according to plan, goes like this...

2200 - Denies pain or discomfort. Nourishment provided. Patient ambulated to BR.

0000 - Sleeping on rounds. NSR 70's on monitor.

0200 - Sleeping on rounds. NRS 70's on monitor.

0400 - Sleeping but wakes easily. Denies pain or discomfort. Labs obtained and sent. EKG completed.

0600 - Sleeping on rounds. NSR 70's on monitor.

Virgo_RN said:
Resting quietly, eyes closed, respirations even and unlabored.

I was taught to use this entry because when their eyes are closed, you can't tell if they are really sleeping, so the word "sleeping" should be avoided. You aren't going to disturb them to find out.

Specializes in floor to ICU.

Hmm. Maybe this is old school but I recall being taught to write something like "No distress noted. Eyes closed, respirations even and unlabored" I recall discouragment from writing the word "appears". I have been know to write that the patient is snoring...

Specializes in Trauma, Teaching.

All I write is "resting quietly, reg and non-labored respirations"

Specializes in ob/gyn med /surg.

pt sleeping resp even and equal unlabored , no s/s of distress at this time, call light personal items within reach , SRx4 up ....

Specializes in Ortho, Neuro, Detox, Tele.

my charting of note is usually "pt resting in bed, eyes closed,breathing regular, no visible s/s of pain."

I note- Pt restig in bed with eyes closed,respirations regular, even and unlabored. arouses easily. No s/s of pain distress observed. personal items, call bell in reach, sr elevated x2.

Pt. in bed resting, eyes closed, no s/s resp. distress noted, call bell within reach.

I was told to write something along these lines because you should never assume anything.

Specializes in Critical Care.

I always say, simply, "pt is resting quietly".

Specializes in icu/er ccrn.

pt noted to be in suspine position with pie hole wide open snoring like a train and copious amounts of saliva stringing from side of mouth.

I was taught this is the one exception to not using "appears".....because to prove they were sleeping, you would have to wake them.....also include a description.

Specializes in Med/Surg, Home Health.

I always charted..."pt resting with eyes closed, no distress noted, RR regular and nonlabored." We did vital signs q 4 hr also.

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