A sleep medicine consult note records the sleep physician’s first visit: the referral question, sleep on work and free days, snoring, sleepiness and driving, insomnia, legs and behaviors in sleep, the exam, the test chosen, and the plan. Copy the free sleep clinic note template, see a commercial driver with loud snoring and a chronic insomnia consult, and check what goes in each part.
Blank sleep medicine consult note template
FreeSLEEP MEDICINE CONSULT NOTE Patient: [Name, age, sex] Date of visit: [Date] Visit type: [New consult or follow-up; in person or video] Referred by: [Name and specialty; bed partner present or not] Sleep physician: [Name, credentials] REFERRAL QUESTION Question asked: [What the referrer wants answered, in their words] Main complaint: [The patient's concern, in their words] Onset and course: [When it started, what set it off, and how it has changed] SLEEP SCHEDULE Work days: [In bed, minutes to fall asleep, night wakings, final waking, out of bed] Free days: [The same times on days off] Sleep against time in bed: [Hours asleep, hours in bed, naps] Routine: [Shift or night work, morning or evening type, screens, caffeine, alcohol, exercise timing] SNORING AND BREATHING Snoring: [Loudness, nights a week, any link to position] Witnessed events: [Pauses, choking or gasping, waking short of breath] Related symptoms: [Morning headache, dry mouth, night-time urination, reflux, nasal blockage] STOP-Bang: [Total out of 8, and the items that scored] SLEEPINESS AND DRIVING Epworth Sleepiness Scale: [Total out of 24, and its range] Sleepiness or fatigue: [Dozes without meaning to, or tired without dozing] Narcolepsy features: [Cataplexy, sleep paralysis, hallucinations at sleep onset or waking, or none] Driving and work: [What and how much the patient drives; drowsy episodes, near misses, crashes; safety-sensitive work] INSOMNIA Pattern: [Trouble falling asleep, staying asleep, or early waking; nights a week; how many months] Insomnia Severity Index: [Total out of 28, and its range] What keeps it going: [Time awake in bed, clock-watching, naps, sleeping in, worry about sleep] Sleep aids tried: [Prescription, over-the-counter, melatonin, alcohol, cannabis, and the effect of each] LEGS AND BEHAVIORS IN SLEEP Restless legs: [Urge to move the legs, worse at rest and in the evening, eased by moving; ferritin and transferrin saturation if present; or none] Behaviors: [Sleepwalking, night terrors, dream enactment, injuries, teeth grinding, limb jerks, or none] HISTORY AND MEDICINES Medical: [Hypertension, heart failure, atrial fibrillation, stroke, lung disease, neuromuscular disease, chronic pain, thyroid disease] Mental health: [Mood, anxiety, bipolar disorder, PTSD; screening scores] Medicines: [Sedating, stimulating, or sleep-altering medicines and their timing; opioids] Substances: [Caffeine, alcohol, cannabis, nicotine, other drugs] Family history: [Sleep apnea, restless legs, narcolepsy, or none] EXAMINATION Vitals and size: [Blood pressure, heart rate, weight, height, BMI] Neck: [Circumference in cm] Upper airway: [Nasal patency, Mallampati class, tonsil grade, palate, jaw position] Other: [Heart, lungs, leg edema, neurological findings that matter] ASSESSMENT AND TEST CHOICE Working diagnoses: [Each sleep diagnosis, with the findings behind it] Contributing factors: [Short sleep, weight, alcohol, medicines, mood, pain] Test: [Home sleep apnea test, in-lab polysomnogram, split-night study, MSLT, actigraphy, sleep diary, or none] Why this test: [Why it fits the patient, or why no test is needed; routine or expedited] PLAN Treatment: [CPAP, oral appliance, positional therapy, CBT-I, weight management, iron, or other] Medicines: [Started, stopped, or deliberately not started, with the reason] Driving and safety: [Advice given, any reporting duty considered under the rules where you practice, and the patient's response] Follow-up: [Results visit, device download, or CBT-I review, with dates; copies to the referrer] Signed: [Sleep physician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Hospital sleep clinic, new consult, in person, 40 minutes
New consult, in person, November 9, 2026. 49-year-old man referred by his family physician: “Loud snoring and daytime sleepiness in a commercial driver. Please assess for sleep apnea and advise on driving.” His concern: “I’m wiped out by two in the afternoon, and my wife has moved to the spare room.” Worse over 3 years, since he gained about 12 kg. His wife joined for the first 15 minutes.
Work days, Monday to Friday: in bed 21:45, asleep within 5 minutes, up twice to pass urine, alarm 04:15; about 6 hours 15 minutes asleep. Free days: in bed 23:30 to 08:30, about 8 hours 30 minutes asleep, and still unrefreshed. Naps 20 minutes in his cab at lunch on 3 days a week. No shift or night work; a morning type. Three energy drinks on work days, the last around 14:00. Three or four beers on Saturdays only.
Loud snoring every night, in every position, heard through the bedroom door. His wife sees pauses in his breathing that end in a snort or gasp most nights. Morning headaches 2 or 3 days a week, dry mouth on waking, night-time urination twice. Occasional heartburn. No nasal blockage. STOP-Bang 6 of 8: snoring, tiredness, observed apneas, treated high blood pressure, neck over 40 cm, and male sex. Age 49 and BMI 32.8 don’t score. High risk.
Epworth Sleepiness Scale 15, moderate excessive daytime sleepiness. Dozes without meaning to as a passenger, in front of the TV, and at his desk on paperwork days. No cataplexy, sleep paralysis, or hallucinations. Drives a regional delivery truck about 9 hours a day, mostly highway. Fights sleep on afternoon runs; pulled over twice last month to nap. No crashes or near misses, and no drifting out of his lane that he knows of.
None. Falls asleep within minutes, and back to sleep quickly after waking to pass urine. Insomnia Severity Index not needed.
No urge to move his legs at rest or in the evening. His wife reports no limb jerks, sleepwalking, or acting out dreams. Grinds his teeth, according to his dentist.
Hypertension for 4 years, on amlodipine. Reflux, with antacids now and then. No heart failure, atrial fibrillation, stroke, lung disease, neuromuscular disease, or chronic pain. No opioids, sedatives, or sleep aids. Mood good; PHQ-9 4. Never smoked; no cannabis. His father snored loudly and used CPAP.
BP 146/92, HR 78 and regular. Weight 104 kg, height 178 cm, BMI 32.8. Neck 44 cm. Nose: both sides patent, mild swelling of the inferior turbinates. Mouth: Mallampati class III, tonsils grade 1, long soft palate. Mild retrognathia. Heart sounds normal; chest clear; no ankle edema.
Obstructive sleep apnea likely, with a high chance of moderate or severe disease: loud nightly snoring, witnessed apneas with gasping, Epworth 15, hypertension, STOP-Bang 6, BMI 32.8, neck 44 cm, and a narrow airway on exam. Short sleep on work days, about 6 hours 15 minutes against 8 hours 30 minutes on free days, adds to his sleepiness. No features of narcolepsy, restless legs, or parasomnia. Test: type III home sleep apnea test. It fits an adult with a high chance of moderate or severe apnea and no heart failure, significant lung disease, neuromuscular weakness, suspected hypoventilation, opioid use, past stroke, or severe insomnia. Expedited because he drives for a living: device pickup November 11. If the result is negative, inconclusive, or technically poor, an in-lab polysomnogram follows.
If apnea is confirmed, auto-CPAP starts at the results visit, with a mask fitting and heated humidity, and a first device download at 2 weeks. Oral appliance discussed as the next option if CPAP fails. Sleep: in bed by 21:00 on work days, for 7 hours asleep. Energy drinks before noon only; no alcohol within 3 hours of bed. Referral to the weight management program. Driving, in general terms under the rules for commercial drivers where he is licensed: don’t drive when drowsy, stop and nap if sleepy, and don’t drive after a short night. He will ask his employer for local routes until treatment works. Explained that untreated apnea with sleepiness can affect fitness to drive commercially, and that falling asleep at the wheel, a near miss, or not using treatment would mean stopping, and could need a report under the rules where we practice. He understood and agreed. Blood pressure above target: letter to his family physician, recheck once on CPAP. Results visit November 17, in person. Copies to his family physician.
Sleep clinic, new consult by video, 45 minutes
New consult by video, November 6, 2026; patient at home, alone. 36-year-old woman, a graphic designer working from home, referred by her family physician: “Chronic insomnia, asking for a sleeping pill. Please advise.” In her words: “I dread going to bed. I lie there for an hour, then wake at three.” Began 2 and a half years ago, when she was laid off, and carried on after she found a new job a year later.
Work days: in bed 22:30, on her phone for 20 minutes, then 60 to 90 minutes to fall asleep. Wakes 2 or 3 times, awake 20 to 40 minutes each time. Alarm 07:00. By her estimate, about 5 hours 50 minutes asleep in 8 hours 30 minutes in bed, an efficiency of about 69%. Free days: in bed 22:30 to 09:30, “trying to catch up,” still about 6 hours asleep. Naps of 45 minutes on 2 or 3 afternoons a week. No shift work. On holidays, a later bedtime makes falling asleep no easier.
Her partner reports no snoring, pauses, or gasping. No morning headaches or night-time urination. STOP-Bang 1 of 8, tiredness only. Low risk.
Epworth Sleepiness Scale 5, lower normal. Tired, irritable, and slow to focus, but doesn’t doze off without meaning to; her naps are planned. Fatigue, not sleepiness. No cataplexy, sleep paralysis, or hallucinations. Drives about 20 minutes a few times a week; no drowsy driving.
Trouble falling asleep and staying asleep, 5 nights a week for 2 and a half years, with daytime fatigue, poor focus, and irritability. Insomnia Severity Index 19, moderate clinical insomnia. Watches the clock, stays in bed when awake, sleeps in on free days, and naps. Believes she “can’t work on less than 8 hours.” Sleep aids: diphenhydramine 50 mg on 3 nights a week for a year, which leaves her groggy until mid-morning; melatonin 5 mg for 2 months, no effect; a glass of wine on 4 or 5 evenings “to switch off.” No cannabis.
No urge to move her legs, at rest or in the evening. No sleepwalking, night terrors, or acting out dreams. Her partner sees no limb jerks.
No chronic medical conditions. TSH and blood count normal in September, per her family physician. PHQ-9 8, with item 9, on thoughts of death or self-harm, scored 0. GAD-7 9; worry is mostly about sleep and work deadlines. No past mental health treatment, no bipolar disorder, and no seizures. No prescription medicines. Three coffees a day, the last around 16:00. Not pregnant. Her mother has “always been a poor sleeper.”
Limited by video. Alert, not sleepy; anxious when talking about nights, otherwise calm. Weight 64 kg and height 167 cm, as she reported, BMI 23. Neck 33 cm, measured at home with a tape. No visible thyroid swelling. Airway not examined, as nothing in the history points to apnea.
Chronic insomnia disorder, with trouble falling and staying asleep, 5 nights a week for 2 and a half years, and daytime effects. Kept going by long hours in bed for under 6 hours of sleep, sleeping in, naps, the phone in bed, clock-watching, afternoon caffeine, evening wine, and the antihistamine. Mild anxiety symptoms, mostly about sleep; reassess after treatment. Sleep apnea, restless legs, a delayed sleep phase, and parasomnia unlikely. Test: no sleep study. Polysomnography isn’t used to diagnose insomnia, and nothing suggests apnea, limb movements, or parasomnia. A two-week sleep diary starts tonight, for CBT-I to build on.
CBT-I with the clinic’s sleep psychologist: 6 weekly video sessions from November 25, covering sleep restriction, stimulus control, and work on her beliefs about sleep. Sleep hygiene advice is part of the course, not a treatment on its own. Until then: the diary each morning, out of bed at 07:00 every day, weekends included, and no naps. Medicines: no hypnotic started. Explained that CBT-I works about as well as sleeping pills in the short term and lasts longer, without next-day effects or dependence; she agreed. Stop diphenhydramine: it causes next-day grogginess, its effect fades with use, and it isn’t recommended for chronic insomnia; a few rough nights are possible. Melatonin stopped, as it didn’t help. Coffee before noon only; no wine as a sleep aid. Medicine to be reconsidered only if CBT-I doesn’t help. Review by video after session 6, with the ISI and diary; aim for an ISI below 8. Letter to her family physician explaining the plan, and why no pill was started.
Why the patient was sent, in the referrer’s words, and what the patient wants from the visit. Sleep referrals often ask one question when the patient has another.
Avoid: Answering only the referral. A patient sent for snoring may be most troubled by insomnia, and the two need different tests.
When the patient sleeps on work days and on free days. The gap between the two often explains sleepiness before any test does.
Avoid: One set of times for the whole week. Six hours asleep on work days and nine on free days points to insufficient sleep.
Symptoms that make obstructive sleep apnea likely, best told by a bed partner.
Avoid: A STOP-Bang total with no items. The reader can’t tell whether it rests on symptoms, or only on age, sex, and neck size.
How sleepy the patient is, whether it is sleepiness or fatigue, and what it means for driving and safety-sensitive work.
Avoid: Reading the Epworth score as an apnea test. Many people with moderate or severe sleep apnea score in the normal range.
Trouble falling or staying asleep, how often, for how long, and what keeps it going.
Avoid: “Poor sleep” with no pattern. Chronic insomnia means at least 3 nights a week for at least 3 months, despite enough chance to sleep, with a daytime effect.
What a home test can’t see: restless legs, limb movements, and behaviors in sleep.
Avoid: Ordering a home test for dream enactment. Diagnosing REM sleep behavior disorder needs an in-lab study with video.
What changes the diagnosis, the choice of test, or the safety of treatment.
Avoid: Missing bipolar disorder or seizures in an insomnia consult. Sleep restriction, a core part of CBT-I, needs extra care in both.
Body size and the upper airway, plus findings that point to another cause.
Avoid: “Crowded airway” with no detail. Write the Mallampati class, tonsil grade, and jaw position, so a dentist or surgeon can use them later.
The working diagnoses, and the test that answers the question, if one is needed.
Avoid: A home test for a patient with heart failure, significant lung disease, neuromuscular weakness, suspected hypoventilation, chronic opioid use, a past stroke, or severe insomnia. They need an in-lab study.
What happens next: treatment, medicines, safety advice, and follow-up.
Avoid: Sleep hygiene as the whole insomnia plan. On its own it rarely fixes chronic insomnia; refer for CBT-I.
Short sleep on work days, sedating medicines, depression, and narcolepsy also cause sleepiness. Read the schedule and history before you order a test, and check sleepiness again once apnea is treated.
For a sleepy patient, ask what they drive, for how long, and about drowsy episodes, near misses, and crashes. Write the advice you gave and any reporting duty you considered. Rules on reporting differ by place, so follow the ones where you practice.
For chronic insomnia in adults, CBT-I comes first. If you prescribe, write why: CBT-I didn’t help, isn’t available, or the patient declined it, and how long the medicine is meant to last.
Restless legs are often described as trouble falling asleep. Ask about the urge to move the legs in the evening, and check ferritin when it is present; low iron is common and treatable.
Vero Scribe writes the sleep consult note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The referral question; the sleep schedule on work days and free days; snoring, witnessed apneas, and the STOP-Bang score; sleepiness, with the Epworth score and driving; insomnia, with the Insomnia Severity Index; restless legs and behaviors in sleep; medical history, medicines, and substances; an exam with BMI, neck size, and the upper airway; the working diagnoses and the test chosen; and the plan, with follow-up.
The consult note records the visit: the history, the exam, which test to order, and the treatment. The sleep study report interprets the recording itself: the AHI, oxygen levels, sleep stages, and severity. A patient with suspected apnea usually has a consult, then a study, then a results visit that starts treatment.
For adults with a high chance of moderate or severe obstructive sleep apnea and no complicating conditions: usually daytime sleepiness plus two of loud snoring, witnessed apneas or gasping, and high blood pressure. Choose an in-lab polysomnogram for significant heart or lung disease, neuromuscular weakness, suspected hypoventilation, chronic opioid use, a past stroke, severe insomnia, or suspected narcolepsy, parasomnia, or limb movement disorder. A negative or failed home test with high suspicion also needs an in-lab study.
CBT for insomnia, or CBT-I. The American College of Physicians and the American Academy of Sleep Medicine both recommend it first for adults. It combines sleep restriction, stimulus control, and cognitive therapy, usually over 4 to 8 sessions, in person, by video, or as a digital program. Sleep hygiene advice alone isn’t enough. Medicine is an option when CBT-I hasn’t worked or isn’t available, after weighing next-day effects and dependence.
Yes. Copy it, or download it as a Word or text file. No account needed.
Study type, scoring rule, sleep stages, AHI or REI, oxygen, heart rhythm, limb movements, severity, and the treatment plan.
Sleep clinic consults and follow-ups, drafted from the visit or your dictation.
How to score it, what each range means, and a template to record it.
The eight items, the risk bands, and the STOP rule for scores of 3 or 4.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
No credit card required. 10 free actions every month.