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!

Specializes in Psych ICU, addictions.

"Patient resting quietly in bed with eyes closed."

Then add on anything that's not normal or quiet (e.g., wheezing, snoring, etc.)

I remember reading that thread on AN too. It made sense. Said something like use the word observe instead of monitor and I believe don't use future tense. Will continue leaves things open to argument, whereas, observed to be ....states you actually observed the patient. Oh, I don't know, all of this is so nit-picking until we get into court.

Yea I used to write continue to monitor for a looong time until I found out we werent supposed to do so. Same thing with writing "error" in a pt chart...if you write in the wrong chart for example I read that we can't write ERROR...we are supposed to write void, delete, etc...instead bc error can be shown as a lack or error in actual care *** hah. Hospitals should give new hires a legal documentation class it would probably be very helpful!!!

caliotter3 said:
I remember reading that thread on AN too. It made sense. Said something like use the word observe instead of monitor and I believe don't use future tense. Will continue leaves things open to argument, whereas, observed to be ....states you actually observed the patient. Oh, I don't know, all of this is so nit-picking until we get into court.

A co-worker doesn't even know the proper way to make corrections to charting on the MAR/TAR. And this is after several months experience working in LTC. The easiest way to correct a missed entry is to just fill in the entry. It is inviting trouble to completely restart a record, causing several nurses, including some who no longer work with the patient, to go back and redo charting. Red flags in court when you redo charting.

Pt resting in bed, arousable to voice. VS per flowsheet. Call light within reach. Denies pain. Denies needs.

bamagt said:
Pt resting in bed, arousable to voice. VS per flowsheet. Call light within reach. Denies pain. Denies needs.

That works when you've gone in to do vitals and you have to wake them up but at our facility we start at 0245, first vitals are at 0400 and then 0800, etc.

If you have a patient that you must monitor more than Q4H . . . but don't go in and wake them up to see if they truly are arousable, then what do you chart?

steph

Specializes in ED, Med-Surg, Psych, Oncology, Hospice.

At one time or another I have probably charted nearly everything cited on these posts. Fact is, I can tell if someone is sleeping and I will chart that. We don't say chest is rising, we are capable of knowing (and charting) respirations. If I am making assumptions beyond my lisensure then take it. Geesh!

Specializes in Surgical Nursing.

We have check boxes on our computer charting program so I usually check..

IV site check done; side rails up X2; bed locked and low; call light in reach; HOB flat (or up 30 degrees or whatever); Knee high PCDs on bilat; Activity: sleeping

Specializes in Community, OB, Nursery.

"Pt in [enter position here], eyes closed, respirations even and unlabored."

Specializes in Psych, Med/Surg, LTC.

I don't chart that a patient is sleeping... B/c how do you know if they are sleeping or just resting? I chart "pt in bed, eyes closed, respirations regular at 18 or whatever respirations per minute. No distress noted." I will also put in snoring if they are snoring.

Specializes in Peds/outpatient FP,derm,allergy/private duty.
OldnurseRN said:
At one time or another I have probably charted nearly everything cited on these posts. Fact is, I can tell if someone is sleeping and I will chart that. We don't say chest is rising, we are capable of knowing (and charting) respirations. If I am making assumptions beyond my lisensure then take it. Geesh!

These things do veer into the silly season at times, don't they? Ah, well. As long as lawyers can find a way to pick things apart (which they always will do) we'll continue to do strange backbends to try to adapt.

The one that bugs me is "kept comfortable at all times, all needs met" but that's for another thread!!

I find it boring to chart the same thing over and over for 18 pt.s when I work 3 nights in a row! I work on an 18 bed, usually always full, pych unit. We work 12 hr. shifts, and are only required to chart once a shift. The RN has to chart all the pt's. We have 1 RN, 1LPN and one Psych Tech on each shift. I am looking for creative ways to say the same thing about the pt's sleeping! It seems so redundant to write: "Pt. is resting quietly with eyes closed, Resps even & unlabored. Another RN told me it is ok to write: "Normal Sleep Pattern observed for this pt. at time of this note..... Any ideas? Thanks! Kathleen RN

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