Diagnostic Polysomnography (PSG) Interpretation Report

Report: Diagnostic Polysomnography (PSG) Interpretation Report

Patient: [Patient full name] | DOB: [Date of birth] | MRN: [Medical record number]

Study date: [Study date] | Facility/Location: [Facility or laboratory name] | Accession/Study ID: [Study identifier]

Ordering/Referring clinician: [Name, credentials]

Interpreting clinician: [Name, credentials]

Report status: [preliminary / final] | Signature date: [Date signed]

Study type: Attended in-lab diagnostic PSG, Type 1

Clinical Indication

(Include only if referral materials provide clinical context; otherwise omit this section entirely.)

• [Reason for study and suspected diagnoses, including key symptoms such as snoring, witnessed apneas, choking/gasping, nocturnal awakenings, excessive daytime sleepiness]
• [Relevant comorbidities: obesity, hypertension, atrial fibrillation, CHF, COPD, neuromuscular disease, opioid use, stroke]
• [Prior sleep testing results if documented]
• [Pre-test screening scores: ESS, STOP-Bang] (Include only if documented.)

Medications and Substances

(List only if documented; omit section entirely if not provided.)

• [Sedatives/hypnotics with dose/timing if available]
• [Opioids]
• [Antidepressants and REM-modifying agents]
• [Gabapentinoids]
• [Stimulants]
• [Alcohol and caffeine intake near bedtime]
• [Supplemental oxygen use and flow rate]

Study Methodology and Scoring

• Recording times: [Lights off / Lights on or Recording start / end times]
• Core channels: [EEG, EOG, chin EMG, airflow sensors, thoracoabdominal effort belts, pulse oximetry, ECG, body position sensor, snore sensor]
• Additional monitoring: [Video / CO2 monitoring (transcutaneous or end-tidal) / Extended EEG montage / Additional EMG leads / None]
• Special conditions: [Supplemental oxygen and flow rate / Positional device / Significant signal loss periods / Technologist interventions] (Include only if applicable.)
• Scoring manual: [AASM Scoring Manual version]
• Hypopnea definition: [Recommended: 3% desaturation and/or arousal / Acceptable: 4% desaturation]
• RERAs scored: [yes / no]; RDI reported: [yes / no]
• Dual AHI reporting: [yes / no] (If yes, report both AHI-3%/arousal and AHI-4% in Results.)

Study Adequacy and Limitations

(Provide 2-5 concise bullets; omit section if no limitations.)

• [Signal quality and any significant data loss with channels affected and duration]
• [Total sleep time adequacy] (Comment if short TST limits severity estimation.)
• [REM and supine time sufficiency] (Comment if limited sampling may underestimate severity or preclude positional/stage analysis.)
• [Behavioral or medication factors impacting study quality]
• [Interpretive impact statement and whether repeat testing is indicated]

Results

(Report objective, measured data only. Indices to one decimal, times in minutes. Omit any subsection where data were not recorded.)

Recording Summary

Time in bed (min)	[TIB]
Total sleep time, TST (min)	[TST]
Sleep efficiency (%)	[Sleep efficiency]
Sleep latency (min)	[Sleep latency]
REM latency (min)	[REM latency]
Wake after sleep onset, WASO (min)	[WASO]
Arousal index (events/h)	[Arousal index]

Sleep Architecture

N1 (min, %)	[N1 minutes] ([N1 %]%)
N2 (min, %)	[N2 minutes] ([N2 %]%)
N3 (min, %)	[N3 minutes] ([N3 %]%)
REM (min, %)	[REM minutes] ([REM %]%)

[Sleep architecture comment] (Include only if abnormalities are clinically notable, e.g., reduced REM due to medication effect, increased N1 from respiratory arousals.)

Respiratory Events

Obstructive apneas (count)	[OA count]
Central apneas (count)	[CA count]
Mixed apneas (count)	[MA count]
Hypopneas (count)	[Hypopnea count]
RERAs (count)	[RERA count] (If scored.)
AHI (events/h)	[AHI value] ([3%/arousal / 4%] definition)
AHI-3%/arousal (events/h)	[AHI-3%/arousal] (If dual reporting.)
AHI-4% (events/h)	[AHI-4%] (If dual reporting.)
RDI (events/h)	[RDI value] (If RERAs scored.)
REM AHI (events/h)	[REM AHI] (REM time: [minutes] min)
NREM AHI (events/h)	[NREM AHI]
Supine AHI (events/h)	[Supine AHI] (Supine time: [minutes] min)
Non-supine AHI (events/h)	[Non-supine AHI]
Cheyne-Stokes / periodic breathing	[present / absent] [Description of burden/pattern if present]

Oxygenation

Mean SpO2 during sleep (%)	[Mean SpO2]
SpO2 nadir (%)	[Nadir SpO2]
Time ≤90% SpO2 (min, % TST)	[Minutes ≤90%] ([Percent TST ≤90%]%)
Time ≤88% SpO2 (min, % TST)	[Minutes ≤88%] ([Percent TST ≤88%]%)
ODI (events/h)	[ODI value] ([3% / 4%] threshold)
Supplemental oxygen	[used / not used]; [Flow rate L/min if used]; [Note if indices calculated on oxygen]

Ventilation/CO2

(Include if CO2 monitoring performed. If hypoventilation was clinically suspected but CO2 was not monitored, state "CO2 monitoring: not performed." Otherwise omit section.)

CO2 monitoring type	[transcutaneous / end-tidal]
Baseline pre-sleep CO2 (mmHg)	[Baseline CO2]
Maximum CO2 during sleep (mmHg)	[Max CO2]
Trend description	[CO2 trend summary]
Hypoventilation assessment	[Meets / does not meet] criteria for sleep-related hypoventilation

Limb Movements

PLMS count	[PLMS count]
PLMS index, PLMI (events/h)	[PLMI]
PLMS arousal index (events/h)	[PLMS arousal index]
REM sleep without atonia (RWA)	[present / absent / not assessed]

Cardiac

Mean heart rate during sleep (bpm)	[Mean HR]
Predominant rhythm	[Sinus rhythm / Atrial fibrillation / Other]
Notable arrhythmias or conduction abnormalities	[Description with temporal association to respiratory events if observed]

Other Notable Findings

(Include only if relevant observations present.)

• [Parasomnia behaviors captured on video, suspected seizure activity, bruxism, vocalizations, or other significant observations]

Interpretation

[Integrated summary: primary diagnostic conclusion, severity anchors (AHI/RDI, oxygen nadir, time below thresholds), obstructive vs central predominance, presence of hypoventilation or disproportionate hypoxemia, salient sleep architecture findings, and any limitations affecting diagnostic confidence] (2-5 sentences synthesizing key findings. Do not introduce unmeasured data.)

• [Primary diagnosis]: [Condition and severity, e.g., obstructive sleep apnea, severe, AHI X.X; note REM-predominant or positional if adequately sampled]
• [Central sleep apnea]: [Central apnea index and context such as periodic breathing pattern or association with CHF/opioids] (Include only if present.)
• [Sleep-related hypoventilation]: [Present based on CO2 criteria] (Only if CO2 monitored and criteria met; otherwise omit.)
• [Sleep-related hypoxemia]: [Description if desaturation is disproportionate to event burden] (Include only if applicable.)
• [Periodic limb movements of sleep]: PLMI [value]; clinical correlation for PLMD required (Include if PLMI elevated.)
• [REM sleep behavior disorder concern]: PSG demonstrates RWA; clinical correlation required for diagnosis (Include only if RWA present.)
• [Parasomnia or seizure concern]: [Finding concerning for specific condition]; recommend confirmatory evaluation (Include only if relevant.)

Recommendations

(Numbered, actionable list aligned to diagnoses. Include follow-up timeframes. Omit items not applicable.)

1. Sleep-disordered breathing: [Initiate APAP / Schedule in-lab PAP titration]; [Positional therapy if positional dependence documented with adequate sampling]; [Oral appliance referral for mild-moderate OSA or PAP intolerance]; [ENT evaluation if anatomic contributors suspected]; [Weight management counseling]. Follow-up in sleep clinic within [timeframe] weeks with adherence and efficacy data.
2. Hypoxemia/hypoventilation: [Evaluate for contributing cardiopulmonary disease or obesity hypoventilation]; [Address supplemental oxygen needs if residual desaturation on oxygen].
3. PLMS/RLS evaluation: [Clinical correlation for PLMD]; [Iron studies and medication review] (Include if PLMI elevated with symptoms.)
4. Safety counseling: Advise avoidance of drowsy driving and use caution with sedatives/alcohol until adequately treated.
5. Repeat or alternative testing: [Recommend repeat PSG or alternative testing] (Include if study limitations materially compromise diagnostic confidence.)

Authentication

Distribution: [Method of referring clinician notification]; [Patient follow-up pathway]

Interpreting clinician electronic signature: [Name, credentials] | [Date/time]

Attestation: [Reviewed and attested by board-certified sleep medicine physician: Name, credentials, date] (Include only if required by local policy.)