Documentation & Record Keeping Flashcards

The term 'total recording time' (TRT) in PSG documentation is defined as:

Answer: The interval from lights off to lights on

TRT is the entire lights-off to lights-on period and serves as the denominator for calculating sleep efficiency.

A scored epoch is classified as Wake (W) when alpha or other waking EEG activity occupies more than what fraction of the epoch per AASM rules?

Answer: 50%

Per AASM scoring rules, an epoch is scored Wake when more than 50% contains alpha or low-amplitude mixed-frequency activity characteristic of wakefulness.

During a home sleep apnea test (HSAT), the patient log completed by the patient serves primarily to:

Answer: Document lights off/on times and any interruptions not captured by the device

Because no technician is present, the patient log captures key timestamps and events (getting up, equipment problems) needed to interpret device data accurately.

When an AASM-required 10-minute inter-scorer reliability check is performed, the acceptable minimum agreement for sleep staging is:

Answer: 80% epoch-by-epoch agreement

AASM accreditation standards require a minimum of 80% epoch-by-epoch agreement between scorers on sleep staging during inter-scorer reliability assessments.

A CAP (cyclic alternating pattern) notation in technician comments indicates documentation of:

Answer: A periodic EEG pattern of NREM instability with alternating A (activation) and B (background) phases

CAP is an NREM sleep EEG marker of sleep instability, with phase A (phasic activation bursts) alternating with phase B (background), relevant to sleep fragmentation analysis.

If a fire evacuation occurs mid-study, which documentation action is most critical immediately after the emergency?

Answer: Record the exact time the study was interrupted, events that occurred, and the patient's status

Any study interruption must be immediately logged in the PSG record with timestamp and patient status to ensure data integrity and patient safety documentation.

Which statement about documenting periodic limb movements (PLMs) is correct per AASM rules?

Answer: PLMs are scored in series of ≥4 consecutive movements with inter-movement intervals of 5–90 seconds

A PLM series requires ≥4 movements, each lasting 0.5–10 seconds, separated by intervals of 5–90 seconds, and can occur in any sleep stage.