PERSONAL SUPPORT COMMUNICATIONS AND RECORDS
MANAGEMENT
ASSIGNMENT 4 – DOCUMENTATION
PURPOSE
1. The purpose of Assignment 4 – Documentation is to introduce students to the various elements
of paper/electronic documentation
2. The tools used in this assignment will help students understand the concepts of documentation,
legal writing, approved medical terms, abbreviations, and formats of charting
ASSIGNMENT OBJECTIVES
1. Understand the basic concepts of paper/electronic documentation by charting on a given
patient scenario
2. Understand the concepts of subjective and object data and practice inputting these data classes
into appropriate format in documentation
3. Understand chart formatting, professional signing off, and 24-hour time in charting
4. Demonstrate the ability to conceptualize patient data and to organize the material into clear,
concise, and acceptable means
5. Students can use SOAP, narrative, PIE, DAR, or any approved method of charting in this
assignment
PLAGIARISM AND ACADEMIC HONESTY POLICY
1. Plagiarism is defined as “the practice of taking someone else’s work or ideas and passing them off as
your own without appropriate credit” (Oxford Dictionary, 2022)
2. All work presented in this assignment must of the student’s own work
3. Students must not copy other students (past or current students) work and pass that off as their own
assignment
4. Students are able to use the textbook and valid online resources to complete their assignments
MARKING CRITERIA
1. Students are to complete each question in full using acceptable grammar and punctuation
2. All assignments must be typed on a Word or Google document (font size and style is up to the
discretion of the instructor) and submitted via the D2L Brightspace environment as per the
instructor’s direction
3. Allocated marks are presented for each question and students must answer all the sections of
the question for full marks
4. Instructor’s can mark as per their discretion and can award partial marks where warranted
5. The total marks awarded for Assignment 4 – Documentation for Personal Support
Communication and Records Management is 30 marks
6. The passing mark for this assignment is 70%
Personal Support Worker Hybrid Program 2022
PERSONAL SUPPORT COMMUNICATION AND RECORDS
MANAGEMENT
ASSIGNMENT 4 – DOCUMENTATION
/30 Marks
ASSIGNMENT INSTRUCTIONS
1. Please read the entire assignment prior to beginning
2. Your task for this assignment is to chart patient data for Ms. Julia Smith on the given progress
report sheet and the graphic sheet following the patient care scenario presented (scroll down to
see)
3. You may use your textbook and valid online resources to assist you in understanding charting,
documentation, narrative notes, subjective/objective data, etc.
4. The mark for each question is indicated in the parenthesis next to each question
Complete a written progress note and the vital signs flowsheet for the following scenario:
On the 0700–1500 shift you are caring for Ms. Julia Smith, a 44-year-old woman who has a cast on
her left arm. Your supervisor is Sarah Johnson, RN. You are required to assist Ms. Smith with a
bed bath and help her into a clean dressing gown. Although Ms. Smith can independently brush her
teeth and wash her face, she needs constant reminders and encouragement.
Before assisting Ms. Smith with her routine bed bath, you take a set of vitals as it is at the start of
your shift. Ms. Smith’s vitals are as follows:
BP: 155/82 T: 36.8 degrees CelsiusR: 18 bpm HR: 78 bpm
When you help undress your client for her bath, you notice that the cast feels wet and smells foul.
You also notice that Ms. Smith looks sad, a little upset, and is not engaging in conversation as she
normally does. When you ask how she is feeling, Ms. Smith replies that she is “not good” and that
the fingers on her left arm feel “fuzzy and cold”.
Using the following two (2) forms, document what observations you made while caring for Ms. Smith
and any related actions that were taken as per the scenario above.
Personal Support Worker Hybrid Program 2022
(20 marks) FORM 1: PROGRESS NOTES
Date Time Progress Note
March 14 0740 Assisted Ms. Julia Smith, 44-year-old female, with bed bath and dressing gown.
Noticed wet and foul-smelling cast on left arm. Client appears sad and upset, not
engaging in conversation. Client reports fingers on left arm feel "fuzzy and cold".
Actions Taken: Informed RN supervisor Sarah Johnson of observations. Assessed
cast for signs of infection or moisture-related issues. Provided emotional support
and reassurance to client.
Signature/Status of Staff Staff Initials
Y.S. / PSW YS
(10 marks) FORM 2: VITAL SIGNS FLOW SHEET
Vital Signs Flowsheet
Date: March 14
Time: 0720
40
39
Temperature (degrees 38
Celsius) 37
36 36.8
35
Pulse: 78
Respirations: 18
Personal Support Worker Hybrid Program 2022
Blood Pressure: 155/82
Other:
Initials Y.S.
SUBMISSION INSTRUCTIONS
1. Once your assignment is complete, please upload your assignment into the D2L Brightspace
platform in the appropriate submission fields for this course
2. THE DUE DATE IS DETERMINED BY YOUR INSTRUCTOR (please reach out to your
instructor for the exact date and time of all assignment deadlines)
Personal Support Worker Hybrid Program 2022
