Charting for Sleep Technologists: Basic Best Practices in Patient Care
Charting is one of the most basic and important aspects of patient care
Unfortunately charting is also one of the most often slighted duties technologists perform. By slighted I mean that charting is frequently deemed unimportant, and therefore overlooked, done poorly, inaccurately or even not done at all. Importantly, charting is a vital part of any health care provider's job including the physician, the nurse, and even you, the sleep technnologist.
Charting says a lot about the patient, true, but it also says a lot about you as a technnologist when it comes to content, depth, and accuracy. A professional will work to make sure that their charting is accurate and complete as they know their charting is a reflection of themselves as a professional. Here is everything you need to know about charting for sleep technologists:
What is charting?
It is a legal medical record that communicates crucial information to other members of the healthcare team so that they can make accurate and informed decisions about the patient’s future medical treatment. Think about that definition, don’t just skim past it but actually think about that definition and what it implies. Your charting is a LEGAL document that can be used in a court of law.
Your charting impacts the decisions that will be made about the patient’s future health care trajectory. Charting is important, vitally important. You are the eyes and ears of the physician who is not physically present during the study and therefore you must provide them the information they need. Not everything can be garnered from the signals you record and maintain. (Those signals are important and in other articles the importance of correcting artifact in order to produce clear signals and avoid any missed data that could lead to a missed diagnosis has already been discussed in other articles.)
The first thing any medical professional is taught about charting is that if it is not in the chart, you didn’t do it.
This sounds pretty basic but let’s think about that for a bit. Your job it to monitor the patient. If you do not chart regularly on that patient what means do you have to prove you actually did monitor them? Remember this is a legal document. If you get pulled into court what means do you have to prove you were monitoring the patient? Your word and your co-worker’s word will not be sufficient. The law wants facts and supporting documentation; proof. So if you are not charting regularly on a patient throughout the collection, then as far as anyone is concerned, you did not actually monitor that patient. The accuracy of that charting shows that you are not only good at your job, but that you were actually paying attention. So when you chart that the patient is sleeping and they are actually awake, that is a problem.
There should be a policy in your lab about how often to chart during the night and what to chart. If where you work doesn’t have one, they need to make one, but that doesn’t mean you should not chart because of a lack of policy. I’ve written before about the fact that exceptional technologists go above what is asked of them and don’t do just the bare minimum. That said, this doesn’t mean you should get chart crazy either. You need a good balance. Lengthy notes do not always mean relevant notes. Keep things brief, to the point and state facts.
So what should you chart during the study collection as compared to after?
During the study, you are charting what is going on right now with the patient. If you notice that the patient is talking in their sleep, that needs to be documented right now, as it is happening, so that later it can be determined if it is important to the patient's diagnosis. Did it happen when they were in REM or NREM? Before an arousal, after an arousal. You are the eyes and ears of the physician, providing information that supplements and enhances the signals recorded. Information like that is time sensitive and should be charted as it happens and not later.
During the study, regardless of the type of study, you should be routinely charting the patient’s present sleep stage, the heart rate (HR), the respiratory rate (RR), the SpO2, and body position and a general observation since your last charting. When you do this you are providing facts that prove you are observing the patient. You are also providing a back up to the signals that are being recorded. If you say that patient is supine but the signal derivation states left lateral, then you know you need to correct that so that the record is a true reflection of what is actually going on with the patient. If you are performing a diagnostic study, you should also make comments about snoring intensity and frequency, as well as if the patient qualifies for a split night study or not, and why.
If you are performing a titration study then you should also be making comments about the pressure the patient is on and if this pressure is controlling snoring or other events. General comments should include basic factual information about how the patient has done since your last charting. Have they had respiratory events, are they increasing or decreasing? If there is artifact you should be noting the type, where that artifact is and how you are dealing with it. For example; maybe you note that the patient has sweat artifact. You could document that sweat artifact is present and that at the next arousal you will go in to flip the patient’s pillow or turn down the temperature. However, you also need to carry through and actually do that at the patient’s next arousal and you will need to chart that you were in the room and doing just that right after the intervention. As always if you don’t chart you did not do it!
Chart facts, not guesses!
You will note that what I have been listing are simple facts. A guess leaves you open to looking unprofessional and possibly incompetent. Make sure what you are charting is pertinent to the study and appropriate. Be specific and objective, avoid generalizations and subjective statements. What does that mean? If you chart that the patient appears upset that would be subjective. Upset can mean many different things and doesn’t say about what. An objective observation would be to state facts and include signs, symptom, statements and timing. An example would be to chart that at 22:15 the patient was crying, breathing rapidly, and made a specific statement indicating a fear of sleeping tonight without the CPAP they have been using for the past 10 years.
Sadly we do need to talk a bit about inappropriate charting. Nothing you chart should be of a personal nature about the patient. Your patient may be mean, rude, smell badly, and be a curmudgeon but that is inappropriate to chart. It is also inappropriate to chart that the patient is sweet, pretty/handsome, wears nice perfume/cologne, or is adorable. Nor should your charting ever include anything about your feelings, or any excuses or departmental problems.
Examples of what NOT to chart include:
- “The patient refuses to put down her stupid tablet and is still playing Candy Crush”
- “The patient’s blasted phone rang AGAIN”
- “I have asked management three times to get me a new belt because this one is malfunctioning but they have not done it yet therefore I am unable to fix this artifact”
- “I am so bored right now, the patient doesn’t even snore, why they are here is beyond me”.
Many places have present charting notes that pop up for you to check off. Be very careful when using this type of system.
These may provide basic static charting notes that reduces your work but they lack individuality and you can easily miss pertinent information that can impact the patient’s care. There is also the potential to simply check off the information with a copy paste attitude without actually observing the patient. You will always want to supplement these chart notes with your observations. Your assessment is integral to your patient’s care. Check boxes cannot cover everything. Also never pre-fill this type of charting as if things change, there is the potential that your charting will not reflect what is actually happening.
Summarizing the night
You cannot rely solely on charting during the study and you cannot rely solely on summaries. Your summary gives those following after you, the scoring technologist and clinician, a brief overview of what is inside all those detailed individual notes and your general observations to aid them in quickly knowing pertinent information that can impact the patient’s care and outcome.
The summary notes are often templates that help to reduce the charting workload and provide some consistency. Be very careful that you are filling out that template accurately and correctly and are not simply copying and pasting inaccurate or incorrect information. A prime example is a template statement that indicates: “The respiratory events were noted to be worse when sleeping supine.” If this particular patient either did not, or was unable to, sleep supine at all during the study this would be an inappropriate and inaccurate statement. You will want to be careful when using these types of templates so that you don’t simply copy and paste them into the record and neglect to correct them.
An example would be to find the final charting including an unedited statement like: “This is a XX year old male/female patient that presented for a Diagnostic/Split/CPAP Titration/Bi-level Titration/ ASV study.” Templates can be helpful but they can lead to the dangerous practice of simply copying and pasting and being incomplete and inaccurate.
As a professional, you need to take responsibility for your charting. It is an integral part of the care you provide for your patient. You must realize that the patient chart, when it is accurate and well done, is a lifeline to better care, and a badly done chart is not just detrimental to the patient, but also potentially to you professionally.
A final thought for you about charting. When you chart, you are documenting not just what happened with the patient, but you are also charting about all that you do. You work hard to take good care of your patient, why not get the appropriate credit for doing that by making sure your charting reflects your accuracy, and the care and attention you have given to the patient.
Interested in learning more about charting and keeping records for insurance? Check some of out our amazing educational tools!