How To Document Sleeping On Night Shift

[SteffersRN87, BSN, RN]

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.

[caliotter3]

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.

[General E. Speaking, RN, RN]

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...

[JBudd, MSN]

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

[ohmeowzer RN, RN]

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

[locolorenzo22, BSN, RN]

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

[Pink Buttafli]

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.

[PAROPPY, BSN, RN]

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.

[clementinern]

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

[C-DIFF PHIL RN]

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.

[morte, LPN, LVN]

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.

[chenoaspirit, ASN, RN]

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