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!

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.

I'm just curious....why would there be a lawsuit over a patient sleeping vs. resting with eyes closed (assuming both chart patient is breathing, in no distress, etc). What is the issue here?

Specializes in M/S, LTC, Corrections, PDN & drug rehab.
Elle23 said:
I'm just curious....why would there be a lawsuit over a patient sleeping vs. resting with eyes closed (assuming both chart patient is breathing, in no distress, etc). What is the issue here?

Not necessarily a lawsuit over sleeping v. resting with eyes closed but a lawyer could take one more out of context than the other. Also my work told me to quit documenting sleeping since there is no way to prove the patient is sleeping. So I will cover my *** & not put sleeping.

Specializes in med-surg.
mrsjonesRN said:
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.)

I like this one the best. Gonna have to start using it.

OrganizedChaos said:
Not necessarily a lawsuit over sleeping v. resting with eyes closed but a lawyer could take one more out of context than the other. Also my work told me to quit documenting sleeping since there is no way to prove the patient is sleeping. So I will cover my *** & not put sleeping.

I'm guessing that the issue wouldn't necessarily be whether or not the person was sleeping, but to pick apart the documentation as a whole if an issue regarding the care did come up.

i am grateful for your input, I will stop using "sleeping" at all in my notes. Even if I think it is really stupid.

On a side note, I can't tell you how many patients insist they got no sleep at all when they were clearly sleeping all night and everyone around them knew it too!

Iggy123 said:
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!

Never use the word "appears" in your charting. It is a subjective .How do YOU know the patient is sleeping?

Patient is resting with eyes closed, respirations even and non labored COULD cover you.

Refer to your nursing educators and facility policy as to how to document your night shift observations.

How to you document on a client working 11pm to 7 am

How to you document on a client working 11pm to 7 am

Factually ...the same way you would on any other shift.

Anything out of the ordinary, of course, but generally you just chart "Asleep without distress, respirations even/unlabored." That pretty much says it all.

I was told can't chart "asleep", lawyer would say, "How do you know the patient wasn't comatose?" Something along the lines of, "Lying on left side, respirations even and unlabored, skin warm and dry, no apparent distress." Maybe two or four hours later chart, "Patient turns self to back, respirations even and unlabored" etc.

But I really hate charting to "what would a lawyer say".

Specializes in Reproductive & Public Health.

yeah, just an hourly update or some such proof that you kept an eye on them.

Appears asleep could work. It's an option in EPIC. Grrr epic

I work LTC: Resting in bed with eyes closed. VSS, afebrile. Continues on IV antibiotics with no n/v/d. Resp easy and unlabored on room air. Denies pain. Dressing to left lower extremity clean, dry and intact. IV dressing clean dry and intact. No redness, warmth, edema. Both lumens flushed per protocol. Resident remains continent of bowel and bladder. Assist X1 to ambulate to the bathroom with wheeled walker. Bed alarm inplace and functioning. Fall mats intact to both sides of bed. Call bell within reach.

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