How To Document Sleeping On Night Shift

Nurses General Nursing Nursing Q/A

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!

I have always charted that a patient is sleeping but easily arousable or not easily arousable, but I had no idea that anyone ever would be discouraged from saying that. It makes sense now that I see it. Thankfully where I work we chart focus notes by exception, so this doesn't come up. Sheesh, if I had to focus every round...

Specializes in Cardiac Telemetry, ED.

Resting quietly, eyes closed, respirations even and unlabored.

caliotter3 said:
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.

This is interesting because I was taught in school to say "appears" to be sleeping. Because you really can't tell unless you go in and wake them up. And who wants to wake up a sleeping patient?

So, I chart "Appears to be sleeping, respirations even and unlabored".

I can't say "easily arousable" . . .unless I go in and attempt to arouse them.

This is a tough question and always has been . . . :coollook:

steph

Specializes in rehab.
C-DIFF PHIL RN said:
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.

LOL !!

Specializes in Cardiac Telemetry, ED.

I note whether they are easily arousable to voice if there is a question of their LOC, such as post sedation or altered mental status.....otherwise, I don't mention it.

A nursing diagnosis for a male patient may include: Disturbed sleep patern related to pronged priapism

Pt resting with eyes closed, resps even and nonlabored. No signs of distress or discomfort.

Fits on one line (at least for my tiny handwriting ;) )

Specializes in NICU,ICU,ER,MS,CHG.SUP,PSYCH,GERI.
C-DIFF PHIL RN said:
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.

No kidding!! I used to waffel about the chart "sleeping" or "appears to be" but then after >35 years I figured WTH...if I can't tell if someone is asleep or not, I have no business being here!:jester:

Specializes in GSICU, med/surg.
Pink Buttafli said:
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.

Maybe just a slip of the fingers (and pardon my pun ;P), but its 'rouses' not 'arouses'. I write something very very similar to this one, as all information is objective, and is observes, not an opinion of judgment. My eyes can be closed and I very well might not be sleeping. I always write if I hear snoring as its a good way of saying "hey, this nurse actually noticed someting with that patient". If everything sounds too generic, I don't feel my butt is covered enough when a picky lawyer is in doubt (its all about saving our butts for the day we go to court, right?)

Specializes in Peds/outpatient FP,derm,allergy/private duty.
Quote
This is interesting because I was taught in school to say "appears" to be sleeping. Because you really can't tell unless you go in and wake them up. And who wants to wake up a sleeping patient?

So, I chart "Appears to be sleeping, respirations even and unlabored".

I can't say "easily arousable" . . .unless I go in and attempt to arouse them.

This is a tough question and always has been . . . :coollook:

Oh yes, how well I remember that. Never say they "are sleeping". But I always felt it was pretty lame to have to write that when I knew, beyond the shadow of a doubt, that the patient was asleep!! I don't know when "appears to be" morphed into "eyes closed, breathing even and unlabored, etc etc. It added alot more verbiage. Perhaps "appears to be sleeping" could also be "patient expired" so you need to pro-actively document signs of life. ;)

Specializes in LTC, med/surg, hospice.

I write something like this.

Pt lying (or resting) quietly in bed with eyes closed. No acute distress noted. Call light in reach. Will continue to monitor pt.

Specializes in jack of all trades.

CMS came into our unit recently and we were informed that according to thier guidelines "sleeping" is no longer to be used. We were told to utilize "eyes closed, appears to be resting quietly, etc". They actually gigged us for the documentation stating it was unacceptable. I havent located the documentation in the CMS guidelines but would be nice to see it in print.

+ Add a Comment