SLEEP HYGIENE LOG
The purpose of this log is to assess the person's night time behaviour and sleep patterns for 7 days.
Use the "Keys" at right to record the person's activity and the care given during your shift.
Day 1
Caregiver
initials:
Day 2
Caregiver
initials:
Day 3
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
Person’s Name and Identification or CARDEX stamp
0100
0200
0300
0400
0500
0600
 if Asleep
 if Awake
TIME
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
TIME
Caregiver
initials:
Day 4
TIME
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
Caregiver
initials:
Day 5
TIME
Caregiver
initials:
Day 6
TIME
Caregiver
initials:
Day 7
TIME
5
6
7
8
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
9
10
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
ASLEEP
AWAKE
ACTIVITY
CARE
Date:
2
3
4
List other Activities:
ASLEEP
AWAKE
ACTIVITY
CARE
Date:
KEY
1
0600
ASLEEP
AWAKE
ACTIVITY
CARE
Date:
PERSON’S ACTIVITY
Awake in bed
Going to bathroom
Up in room
Up in Lounge
Up in Hall
0700
ASLEEP
AWAKE
ACTIVITY
CARE
Date:
initials:
0800
(date)
ASLEEP
AWAKE
ACTIVITY
CARE
Date:
Caregiver
0700
(date)
ASLEEP
AWAKE
ACTIVITY
CARE
Date:
Date:
TIME
From ____________ to ____________
CARE GIVEN
Reorient
Sedation
Fluids/ food offered
Toilet / Change brief
Reposition
Pain Medication
List Other Care Given:
0700
0800
0900
1000
1100
1200
1300
1400
1500
1600
1700
1800
1900
2000
2100
2200
2300
2400
0100
0200
0300
0400
0500
0600
ASLEEP
AWAKE
ACTIVITY
CARE
Delirium in the Older Person. Island Health. Reviewed 8-2014.
(Source: James Bay Lodge (a CPL facility) Victoria, BC, 2003. Used with permission)
KEY
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