Sleep Medicine Evaluation Note (Hypersomnia/Narcolepsy)

Date of Service: [Date]

Patient: [Full name], [DOB], [MRN]

Encounter Type: [New consultation / Follow-up]

Referring Clinician: [Referring clinician name and credentials] — [Reason for referral]

Historian(s): [Patient / Bed partner / Caregiver] (List all contributors)

Data Sources Reviewed: [Prior sleep studies, PAP adherence data, outside records, sleep diary, actigraphy] (List items actually reviewed)

Chief Concern

[Primary complaint in 1–2 lines, may include brief patient quote]

History of Present Illness

Excessive Daytime Sleepiness Characterization: [Onset and course including age/date of onset, abrupt vs gradual, potential triggers; frequency and daily pattern; contexts of unintentional sleep episodes; presence of irresistible sleep attacks; intentional nap behavior including frequency, timing, duration, and whether naps are refreshing vs unrefreshing; sleep inertia or difficulty waking with duration; estimated 24-hour total sleep time on weekdays vs weekends; functional impact on work, school, relationships, cognition, with specific examples of accidents or near-misses; Epworth Sleepiness Scale score with date] (If ESS not obtained, document reason.)

Cataplexy Assessment: [Trigger(s) especially laughter or positive emotion, surprise, anger; phenomenology including partial weakness of jaw/neck/knees vs generalized collapse; preservation of consciousness and awareness during episodes; typical duration and recovery pattern; frequency as episodes per day or week; injury risk and protective behaviors; features supporting vs arguing against cataplexy compared to syncope, seizure, or other differential considerations] (If cataplexy denied, state: "Cataplexy specifically asked about and denied." If not assessable, document reason and plan to reassess.)

REM-Related Phenomena: [Sleep paralysis with frequency and timing relative to sleep; hypnagogic/hypnopompic hallucinations with modality, frequency, and whether insight is preserved; dream enactment behaviors]

Nighttime Sleep Quality and Sleep Disorder Screen: [Snoring, witnessed apneas, gasping, morning headaches; insomnia symptoms; restless legs symptoms; circadian concerns including delayed phase, shift work, irregular schedule]

Sleep Schedule and Opportunity:

• Work/school schedule: [Schedule and demands]
• Bedtime: [Usual bedtime and estimated sleep onset latency]
• Wake time: [Usual wake time and alarm use]
• Total sleep time: [Estimated hours on weekdays vs weekends]
• Naps: [Frequency, timing, duration; refreshing vs unrefreshing]
• Schedule variability: [Variation across week]
• Adequate sleep opportunity: [Yes / No] — [Rationale, referencing ≥7 hours for adults]
• Sleep extension trial: [Attempted / Not attempted] — [Response if attempted]

Medications and Substances

• Current medications: [Name, dose, timing, indication for each] (Flag sedatives/hypnotics, stimulants/wake-promoting agents, and REM-modulating medications especially antidepressants. Note changes within past 2–6 weeks.)
• Caffeine: [Type(s), estimated daily amount, latest consumption time]
• Alcohol: [Pattern and quantity, timing relative to sleep]
• Nicotine: [Product/form, frequency]
• Cannabis/THC/CBD: [Frequency, route, last use]

[Relevant psychiatric symptoms including depression, anxiety, and timing relative to sleepiness onset; other medical contributors such as hypothyroidism, anemia, chronic pain] (Include only if relevant.)

Prior Sleep Studies

• PSG/HST: [Date, AHI/REI, oxygen nadir, sleep architecture findings] (If referenced but unavailable, note records requested.)
• MSLT: [Date, mean sleep latency, SOREMP count, validity considerations]
• PAP adherence: [Device type, average usage hours, residual AHI, subjective benefit] (If applicable.)
• Actigraphy/Sleep diary: [Date range, average TST, variability, notable findings] (If available.)

Relevant History

• Past medical/surgical history: [Pertinent conditions related to hypersomnolence differential]
• Family history: [Narcolepsy, hypersomnia, sleep apnea, other relevant conditions]
• Social/occupational: [Occupation, safety-sensitive duties or commercial driving, typical driving exposure, bed partner availability]

Review of Systems

• Neurologic: [Headaches, syncope, seizure history, symptoms relevant to cataplexy mimics]
• Psychiatric: [Mood symptoms, hallucination context]
• Cardiovascular/Pulmonary: [Symptoms of sleep-disordered breathing, syncope if drop attacks unclear]
• Endocrine: [Thyroid symptoms, weight change] (If relevant.)

Physical Examination

• Vitals: [BP, HR, RR, SpO2, Height, Weight, BMI]
• General: [Appearance, observed alertness during visit]
• HEENT/Airway: [Nasal patency, tonsil size, tongue size, Mallampati class, jaw position]
• Neck/CV/Pulm: [Neck circumference, heart sounds, lung exam]
• Neurologic: [Tone, strength, gait, focal findings] (Important if cataplexy or drop episodes reported.)
• Mental status: [Orientation, attention, affect] (Comment if hallucinations reported.)

Assessment

(Problem-oriented assessment with one-line summary and key supporting/conflicting features for each. Do not diagnose narcolepsy without objective testing unless prior definitive results exist.)

1. Excessive daytime sleepiness: [Severity, pattern, functional impact summary]
2. Differential diagnosis: [Likelihood assessment of narcolepsy type 1 vs type 2 vs idiopathic hypersomnia vs other etiologies with brief rationale] (Use "possible cataplexy" if features uncertain.)
3. Insufficient sleep or circadian misalignment: [Contributor: Yes / No / Possible] — [Rationale]
4. Sleep-disordered breathing: [Primary concern / Ruled out / Residual sleepiness despite treated OSA]
5. Medication/substance contribution: [Potential sedating or REM-modulating agents affecting sleepiness or testing validity]
6. Safety risk: [Drowsy driving and occupational safety assessment]

Plan

Safety Counseling

(Required section—must be documented for every encounter.)

• Risk discussion: [Drowsy driving risks discussed, patient-specific factors including near-misses, commute length, commercial driving, machinery operation]
• Countermeasures reviewed: [Do not drive when sleepy, pull over for nap, avoid monotonous driving, arrange alternative transportation, planned naps before risk periods]
• Patient understanding: [Patient verbalized understanding and agreed safety plan]

Diagnostic Testing

Medical necessity: [Excessive daytime sleepiness with features concerning for central hypersomnolence requiring objective confirmation and exclusion of other sleep disorders]

• Ordered: Attended overnight PSG followed by next-day MSLT
• Pre-test requirements:
  • Maintain regular sleep schedule with ≥7 hours opportunity for [duration] prior to testing
  • Sleep diary [and/or actigraphy] for [1–2 weeks] prior to testing
  • [For patients with OSA: continue PAP with current settings during PSG; confirm adequate adherence]
  • Testing will be postponed if: insufficient sleep on diary/actigraphy, acute illness, incomplete medication washout, uncontrolled sleep apnea

Medication and Substance Management for Testing

• Medications to discontinue/taper: [List specific medications, washout start date targeting ≥2 weeks before MSLT, coordinating prescriber if applicable]
• Safety considerations: [Taper precautions, collaboration with psychiatry/primary care as needed]
• Caffeine: [Abstain starting date / Taper plan]
• Cannabis/THC/CBD: [Abstain starting date / Taper plan]

(If washout not feasible, document rationale and plan for qualified interpretation of MSLT results.)

Behavioral Management

• [Sleep extension trial with target bedtime/wake time and TST goals] (If opportunity inadequate.)
• [Schedule regularization and circadian guidance] (If circadian issues suspected.)
• [Strategic scheduled naps: timing and duration]
• [Workplace or school accommodations] (If safety or functioning impacted.)

Pharmacologic Management

[If initiating wake-promoting therapy before confirmatory testing: document rationale based on severity/safety/functional necessity, agent and dose, and how this affects testing timing or interpretation] (If deferring pharmacotherapy, document rationale.)

Follow-up

• Timing: [After PSG/MSLT results / Sooner if safety concerns]
• Next steps based on results: [Treatment initiation / CSF hypocretin testing consideration / Repeat MSLT / Alternative diagnostic pathway]

Orders

• Overnight in-lab PSG
• MSLT (next day following PSG)
• [Actigraphy for specified duration] (If ordered.)
• [Sleep diary for specified duration]
• [Labs: TSH, ferritin/iron panel, other] (Only if clinically indicated.)
• [Referrals: Psychiatry for medication taper coordination, Neurology if seizure differential] (If applicable.)

(Omit subsections that are not applicable. Required documentation even if negative: cataplexy asked and denied, ESS not obtained with reason, medication washout plan or rationale if not feasible.)