Documentation & Record Keeping Flashcards

The European Data Format (EDF/EDF+) is significant in sleep documentation because it:

Answer: Provides a standardized digital file format allowing interoperability between different PSG systems

EDF and EDF+ are universal biosignal formats ensuring PSG data can be read by different scoring software and shared across institutions.

When scoring respiratory effort-related arousals (RERAs), documentation must include:

Answer: A sequence of breaths with increasing effort lasting ≥10 seconds leading to an arousal

A RERA requires a ≥10-second sequence of increasing respiratory effort culminating in arousal without meeting apnea or hypopnea criteria.

A technician documents 'alpha intrusion' in the comments. This finding refers to:

Answer: Alpha frequency activity (8–13 Hz) appearing during NREM sleep stages

Alpha intrusion is the appearance of alpha rhythms during NREM sleep, often seen in chronic pain or fibromyalgia patients and is clinically noteworthy.

Which action is required when a PSG report is amended after the interpreting physician signs it?

Answer: Create an addendum with date, reason for change, and new physician signature—never alter the original

Amendments to signed medical records must be addenda—the original signed document must remain intact to preserve the audit trail.

For pediatric PSG, AASM recommends a minimum paper speed (or display equivalent) of:

Answer: 30 mm/sec (10-second epochs)

AASM pediatric guidelines recommend a display equivalent of 30 mm/sec (10-second epoch view) because pediatric EEG features occur at higher frequencies.

The Respiratory Disturbance Index (RDI) differs from the AHI in documentation by including:

Answer: Apneas, hypopneas, AND respiratory effort-related arousals (RERAs)

RDI = (apneas + hypopneas + RERAs) ÷ total sleep time in hours, making it a broader measure of respiratory disturbance than AHI alone.

When transcribing CPAP titration pressure data into the final report, the technician should document:

Answer: Starting pressure, peak pressure, and final effective pressure with corresponding times

A complete titration record includes temporal pressure changes—start, peak, and final effective pressure—to allow the prescribing clinician to choose the optimal setting.