Question about charting?

[Lorie P.]

i was just wondering if any of you wonderful pd nurse ever chart that your pt is sleeping? i never did when i worked in a hospital. i would chart, pt resting with eyes closed, resp even and unlabored with no s/s distress noted, or something along those lines.

but now that i only have the one pt and she is an infant, i know when she is sleeping. just wondering cause of the ole cover ya butt issues

thanks so much.

[caliotter3]

Who are you charting for? My private duty case had a notebook kept for the mother, where the nurses would put a narrative shift summary. I never used this. Otherwise, for my agency cases, I always charted on the agency form the way they wanted it. Most of my cases have been peds and night shift so I encounter a lot of sleeping. I write a blanket statement like the one you mentioned. You kind of have to say something to indicate they are resting comfortably and not in distress. Otherwise it looks like too much of nothing. At one of my other agency cases, though, the nurses would actually write the word "sleeping" and even though the charting instructions were explicit about not saying things like "watching TV", they would chart watching tv and even put down the name of the show! Very unprofessional. I said something about this to the primary nurse and she gave me the reason why they charted like this. She said that all the nurses knew that the family copied the nurses notes and had used them in a successful lawsuit in the past, therefore they made sure that their notes did not state anything useful.

[liveyourlife747]

i always chart a blanket statement like the OP posted. I work a lot of night shift, so the clients are mostly always sleeping. i put it down because with my agency-- if you didn't write it down, it didn't happen. atleast i know i am covering my butt with the night shift because of the tendency for nurses to drift off. atleast i have hourly notes stating that the person was sleeping and if they are hooked to monitors, what their pulse ox hr and rr was.

[dolphn545]

I work agency, and make a notation every hour. So if my client is sleeping the day away, I will write every hour "remains sleeping" "sleeping soundly", etc.

[jayne109, RN]

My pt is a 5 month old and her two modes are screaming and sleeping. So I chart Pt sleeping or Pt fussy, whatever. Mom always checks my charting so I am sure to chart what she is doing EVERY HOUR. Just my two cents.