Island Health Sleep Wake Monitoring
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1SLEEP – WAKE MONITORING
Mark a dot in the box indicating Asleep or Awake at hourly intervals.
This sheet will allow us to see patterns of sleep and wakefulness in response to
medication or other interventions.
Patient’s Name: ______________________________________
Nights
Days
Evenings
Time
23
24
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
Hours
Date:
Sedation?
Yes
Asleep
No
Awake
Repeat
Sedation?
Date:
Yes
Asleep
No
Awake
Repeat
Date:
Sedation?
Yes
Asleep
No
Awake
Repeat
Date:
Sedation?
Yes
Asleep
No
Awake
Repeat
Date:
Sedation?
Yes
Asleep
No
Awake
Repeat
Date:
Sedation?
Yes
Asleep
No
Awake
Repeat
Sedation?
Date:
Yes
Asleep
No
Awake
Repeat
Adapted with permission from Sleep Chart. Geriatric Psychiatry, Providence Health Care, 2004.
Delirium in the Older Person: A Medical Emergency. Island Health.
Sleep-Wake Monitoring. Reviewed: 8-2014
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