How To Document Sleeping On Night Shift

What Members Are Saying (AI-Generated Summary)

Members are discussing the appropriate way to document a patient's status in medical charts, specifically focusing on whether to use the term "sleeping" or "resting with eyes closed" to avoid potential legal issues. Some users suggest using more detailed descriptions to cover themselves, while others express frustration at the need to be cautious in their documentation. The conversation also touches on the use of the term "appears to be sleeping" and the potential for lawyers to scrutinize charting language.

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 ED, med-surg, peri op.

I’m glad I’m not in the USA. Just writing that a pt slept seems like a big deal. All I write is: pt appears to have slept well. Nil concerns.

Specializes in ICU.
On 12/9/2009 at 9:59 PM, 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.

Yes! I'm saving this ?

I recently read on allnurses somewhere that we arent supposed to write "will continue to monitor pt" as it can be used against the nurse in court if something happens to the patient...because you write will continue to monitor, if something happens they can argue that you were NOT monitoring the patient...can anyone explain this further? I just recently read this in NURSING magazine and also right on allnurses

Quote
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.

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