Assess sleep in the context of the skilled reason and document the judgment:
The sleep-wake pattern and any change (day-night reversal, new nighttime wakefulness/agitation), and the effect of sleep on daytime participation in the skilled plan.
For CPAP/BiPAP: the device settings per order, mask fit and tolerance, adherence, and any desaturation or apnea observed; oxygen if used.
Contributing factors — pain, dyspnea, nocturia, medication, environment — and, for a sleep-wake reversal, a delirium screen (route to Cognitive).
MDS-supportive data
CPAP/BiPAP is coded in MDS Section O0110 (respiratory treatment); the sleep item is captured within the Section D mood screen; the diagnosis in Section I. The record must document the device management, the sleep-wake pattern, and any change so the MDS is supported.
