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!

You don't know that they are actually sleeping, that's where the appears part comes in.

Specializes in M/S, LTC, Corrections, PDN & drug rehab.
NightOwl0624 said:
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 :( ?

All I know is you can get really grilled by a lawyer if you use 'sleeping'. You have no way to tell if the patient is sleeping or not. I wouldn't even put appears to be sleeping. I put laying in bed resting with eyes closed. There is no way for a lawyer to come at me & say anything about that. Just look at your documentation from a lawyers point of view.

Specializes in M/S, LTC, Corrections, PDN & drug rehab.
sarahmarie14 said:
You don't know that they are actually sleeping, that's where the appears part comes in.

I wouldn't put anything about sleeping because to me, it just sets you up for a lawyer to grill you. Don't say anything about sleeping because a lawyer can twist your words.

Specializes in Dialysis.

Also not supposed to write "will continue to monitor" unless you note what you are monitoring, example: "will continue to monitor for s/s of respiratory distress". Last 2 employers have stressed that like crazy

Specializes in Med-Surg.

We use "patient appears to be asleep/sleeping". I work at a very large hospital that uses EPIC charting. It's a commonly used option in the flow sheet, especially for hourly rounding.

I chart "Patient resting quietly with eyes closed. Respirations regular, unlabored. No s/s of distress. Call light and needs in reach. Bed alarm in use.)

Specializes in Pediatric Critical Care.
nortonplusRN said:
How do you know they are "sleeping" a lawyer might ask.

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

But how do you know they are resting!?

Specializes in Pediatric Critical Care.
OrganizedChaos said:
I wouldn't put anything about sleeping because to me, it just sets you up for a lawyer to grill you. Don't say anything about sleeping because a lawyer can twist your words.

You are right. But it's ridiculous that this happens. For goodness sakes!

Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Janey496 said:
But how do you know they are resting!?

Because they are not doing anything, they are laying down recovering. I'm going to cover my *** & put resting.

Specializes in Pediatric Critical Care.
OrganizedChaos said:
Because they are not doing anything, they are laying down recovering. I'm going to cover my *** & put resting.

What if they are laying with their eyes closed, riddled with anxiety? :p

Sorry, just practicing my lawyer skills! ;)

Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Janey496 said:
What if they are laying with their eyes closed, riddled with anxiety? :p

Sorry, just practicing my lawyer skills! ;)

Resting in bed but anxious. Those are two different things. One is an action & the other is a feeling.

No one can say for sure if a person is sleeping or not. There are good fakers out there, I have done it myself on occasion. But even a 3 year old knows the signs of a person sleeping and can identify if such a person appears to be asleep. Sad that we need to "cover our butts" about something like this.

We we use Epic, and one of the options for reassessing pain is "sleeping, easily aroused". If I am checking a patients pain level 30 minutes after administering an IV pain med and they appear to be asleep, I select this option. And I cringe every time. I am certainly not going to wake someone up who appears to be asleep to see if they are still in pain, but I also don't know if they are "easily arouseable" unless I actually try to wake them up. I think this is even worse than stating "appears asleep" in a note, but it is what we are supposed to do.

And I certainly don't want to be grilled by a lawyer over something like this!

Ugggg, the absurdity of the whole thing.

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