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!

[Quark09]

I'll usually write "pt resting quietly; eyes closed, VSS, NAD at present". Depending on what pt has been admitted for (resp. distress, cardiac, etc) I'll do extra notes on that specific area as well.

[littlelimabean01, LPN]

I am pretty new to working the night shift (I should not even be awake right now!) Anyway, I feel my notes are so generic, but true, i.e., even unlabored breathing, resting eyes closed, easily aroused for medication. I HATE this!! I feel like some how I am inadequate in my charting. I want to give more of a specific and through picture of my resident, but they are generally asleep (resting quietly eyes closed). I do feel very scattered when trying to compose a note. I feel this way because there are many things i could say, but I just want to give a "Complete and comprehensive " assessment. My facility is still on paper charting and we have the front which is a body system check mark, then we have to make a narrative note on the back. I have never been told anything about my notes, but I just feel weak in this department.

[MPKH, BSN, RN]

I just chart the following: resting in bed with eyes closed, non laboured visible respirations noted.

[Geslina, BSN, RN]

I put "pt sleeping comfortably, call bell in reach"

[nortonplusRN]

Geslina said:

I put "pt sleeping comfortably, call bell in reach"

How do you know they are "sleeping" a lawyer might ask.

I was told to chart "resting in bed with eyes closed".

[nolanurse88]

I put pretty much the same. Pt. is asleep, eyes closed, chest rising and falling, call bell within reach. Will continue to monitor.

[OrganizedChaos, LVN]

nolanurse88 said:

I put pretty much the same. Pt. is asleep, eyes closed, chest rising and falling, call bell within reach. Will continue to monitor.

I was told you can't put sleeping any longer. You can put pt. is in bed with eyes closed, no pain, resting, etc etc. I use to put sleeping but not any more!

[MPKH, BSN, RN]

I chart "Resting in bed with eyes closed, visible respirations noted. Call bell in reach, siderails x 2. " I modify that as needed for each patient--if the breathing is laboured, I say so. If their eyes are opened, I say so. If they have 3 siderails up, I say so..etc etc etc

[sarahmarie14]

I was always told you could say appears to be sleeping.

[OrganizedChaos, LVN]

sarahmarie14 said:

I was always told you could say appears to be sleeping.

How do you know they are actually sleeping?

[NightOwl0624]

OrganizedChaos said:

How do you know they are actually sleeping?

If you said "patient is sleeping" I could see the problem, but I don't understand why you shouldn't say "appears to be sleeping". They might be sleeping or they might not be, but with all of our assessment skills, we can't determine if they appear to be sleeping?

I guess i better change my documentation verbiage, I've been doing this for years but I had no idea this was so complicated ?

[calivianya, BSN, RN]

Unless the patient is snoring, there really isn't a way to tell when he/she is sleeping. You could argue that they're sleeping if you observe the rapid eye movements associated with REM sleep, I suppose, but if they're not in REM and not snoring, there's not a way to tell. I know I have run into a couple of patients like me who will lay perfectly still with eyes closed and breathe slowly in the hopes that they will get sleepy and fall asleep - it doesn't mean they're sleeping. It always startles me when I think they're out and I go to do something, and their eyes fly open because they weren't sleeping at all. Probably startles both of us, I guess.

Fortunately, I just check boxes on the EMR, so the way I usually document sleep is changing the opens eyes category on the GCS from a 4 to a 3, changing the LOC from alert to drowsy, and changing the RASS from 0 to -1. There is nowhere to document sleep that I am aware of in the regular assessment flowsheet.