Sleep Continuation Note Template

Sleep Follow Up Note
Subjective:
- The patient describes ongoing challenges with falling asleep and frequent nighttime awakenings, resulting in daytime fatigue. The patient is here to discuss these persistent sleep disturbances and explore possible treatment options. The patient has a history of insomnia and has previously undergone a sleep study that confirmed mild sleep apnea. Past treatments included cognitive behavioral therapy for insomnia (CBT-I) and melatonin supplements.
- The patient is currently taking melatonin 5mg nightly and valerian root as a herbal supplement.
- The patient works night shifts, which disrupts their sleep schedule, and consumes caffeine in the evenings to remain alert.
- The patient has no known allergies.
PAP Therapy
- The patient is using CPAP therapy for sleep apnea. They report pressure intolerance and have discussed the need for increased pressure settings. The mask fit is comfortable with no noted leaks. The home care company providing CPAP supplies is SleepWell Inc. The patient perceives a benefit in reduced snoring. CPAP compliance data shows usage on 20 out of 30 days, with 70% of days used for more than 4 hours. Average use is 5 hours per night. Settings discussed include a pressure median of 8 cmH2O and a max of 12 cmH2O. Residual AHI is 5.2, with a CAI of 1.0. No significant vibratory snore index noted.
ROS
- The patient reports recent headaches and nasal congestion.
Sleep / Circadian Pattern
- The patient sleeps at home with their partner. The head of the bed is flat, and they use two pillows under their head. The patient sleeps primarily on their side.
- Weeknight bedtime is around 11:00 PM, with lights out by 11:30 PM. On weekends, bedtime shifts to 1:00 AM with lights out by 1:30 AM. The patient uses their phone in bed for about 30 minutes before sleeping.
- Sleep latency is approximately 45 minutes.
- The patient often stays in bed watching TV before falling asleep.
- The patient wakes up multiple times during the night, with awakenings lasting 10-15 minutes each.
- Weekday wake time is 7:00 AM, while weekend wake time is 9:00 AM. An alarm is used on weekdays.
- The patient spends about 8 hours in bed but estimates only 6 hours of actual sleep.
- The patient prefers staying up late and feels more awake at night.
Daytime Symptoms
- The patient experiences low energy upon awakening and reports daytime sleepiness, particularly in the afternoon.
- The patient occasionally naps for 30 minutes in the afternoon.
- Cognitive symptoms include difficulty concentrating at work.
- The patient has experienced sleepiness while driving but no accidents or close calls.
Objective:
- Physical examination reveals mild nasal congestion and slight paleness.
- Recent sleep study results confirm mild obstructive sleep apnea with an AHI of 10.
Assessment:
- The patient is diagnosed with chronic insomnia and mild obstructive sleep apnea.
Plan:
- Continue CPAP therapy with adjusted pressure settings. Recommend CBT-I sessions to address insomnia. Advise reducing caffeine intake in the evening.
- Schedule a follow-up appointment in 3 months. Consider referral to a sleep specialist if symptoms persist.
- Educate the patient on sleep hygiene practices, including maintaining a consistent sleep schedule and reducing screen time before bed.