Documentation & Record Keeping Flashcards

Which AASM-required parameter must be documented in the PSG header for every sleep study?

Answer: Patient date of birth and study date

AASM standards require that patient demographic information including date of birth and the study date appear in the PSG header.

When a patient removes their own electrode during the night, the technician should document:

Answer: The time of removal, electrode affected, and corrective action taken

Any patient-initiated electrode removal must be noted in the technician comments with time, electrode site, and what was done to correct it.

The AASM Manual requires that slow-wave sleep (N3) epochs be documented when slow waves occupy at least what percentage of the epoch?

Answer: 20%

Per AASM rules, N3 is scored when 20% or more of the epoch contains slow waves (≥75 µV peak-to-peak, 0.5–2 Hz).

A technician notices an artifact that resembles an apnea event. The correct documentation approach is to:

Answer: Note the artifact in technician comments and exclude the segment from respiratory scoring

Artifactual signals that mimic respiratory events must be flagged in comments and excluded from scoring to prevent false AHI elevation.

Which document serves as the primary legal record linking a sleep technician to a specific study?

Answer: The technician's signed attestation or signature on the PSG report

The technician's signature or electronic attestation on the final report establishes legal accountability for the study's conduct and scoring.

Under HIPAA, a patient requests a copy of their PSG data. The facility must comply within:

Answer: 30 days (with one 30-day extension if needed)

HIPAA's Access Rule requires covered entities to provide requested records within 30 days, extendable by one additional 30-day period with written notice.

The split-night protocol change from diagnostic to titration should be documented by recording:

Answer: Exact clock time of the protocol change and CPAP pressure at initiation

The precise time the protocol changed and the starting CPAP pressure are essential for interpreting AHI values from each study phase independently.