Documentation & Record Keeping Flashcards

Which scoring rule applies when both an arousal and a respiratory event end at the same epoch boundary?

Answer: Score both the respiratory event and the arousal separately

AASM rules allow respiratory events and arousals to be scored independently even when they share a time boundary, so both must be documented.

A calibration record showing electrode impedances should be retained for a minimum of:

Answer: The same retention period as the full PSG record (typically 7–10 years per facility/state policy)

Calibration and impedance logs are part of the study record and must be retained for the same duration as the PSG report itself.

In PSG documentation, 'lights off' time refers to:

Answer: The clock time when the patient was instructed to attempt sleep

Lights off is the standardized start of the sleep opportunity period, and all latency measures (sleep onset, REM) are calculated from this reference point.

If a patient reports taking a sleep medication not listed on intake paperwork, the technician must:

Answer: Add it to the study documentation and notify the interpreting physician

Undisclosed medications can alter sleep architecture and must be added to the record and brought to the interpreting physician's attention.

Body position during a PSG is most commonly recorded using:

Answer: A position sensor whose data is embedded as a channel in the EDF/PSG file

A body position sensor channel synchronized with the recording allows precise correlation of position with respiratory events and sleep stages.

An 'out of bed' period must be documented in the sleep log because it affects the calculation of:

Answer: Total sleep time and sleep efficiency

Out-of-bed periods reduce time in bed and must be accurately documented to prevent incorrect inflation of total sleep time and sleep efficiency.

Which element is required in a MSLT (Multiple Sleep Latency Test) documentation that is NOT required in a standard overnight PSG report?

Answer: Nap trial start/end times and whether REM sleep occurred in each nap

MSLT reports must document the exact start and end of each nap opportunity and presence or absence of sleep-onset REM periods (SOREMPs) per nap.