NORTHWESTERN STATE UNIVERSITY

FOURTH LEVEL CLINICAL

NURSE PROCESS RECORDING EVALUATION TOOL

Student Name:__________________________ Date:______________

BEHAVIOR 5 4 3 2 1
Initiates IPA with introduction of self
Ascertains identity of client
Records interaction as close to verbatim as possible
Establishes measurable goal of IPA
Reaches goal of IPA
Identifies emergent goal(s) of IPA
Identifies nursing diagnosis for this client
Utilizes open-ended techniques
Utilizes varied therapeutic techniques
Allows time for client responses
Identifies nontherapeutic techniques
States alternative techniques
Demonstrates active listening behaviors
Describes milieu in clear descriptive terms
Recorded IPA in understandable format
Demonstrates self-awareness in analysis of IPA
Summarized own strength
Identifies themes in interaction
Focused and in-depth exploration of client issues
Assessed context of issues
0 Omitted
1 Minimally done
2 Satisfactorily done
3 Well done
4 Excellently done
NURSE PROCESS RECORDING

Students must use the format in the resource packet for IPAs, it may be copied. Blue or
black ink is required. Students must write legibly or the instructor may require the
assignment to be typed.

The interaction between the client and nurse should be recorded as close to verbatim as
possible and includes nonverbal process communications.

The written framework of an IPA starts with a cover page that contains the client-
centered, measurable goal of the interaction, a clear description of the client’s appearance
and medical diagnosis.

The IPA has beginning, middle and end stages. The beginning should include broad
openings and introduction of self to client. The middle stage is focused on therapeutic
communication techniques and encouraging the client to tell his/her story, the end
includes a temporary or permanent termination of the nurse-client relationship. The
analysis of the stages should reflect on goal attainment and self-awareness. A
psychosocial problem should be the guide for the nursing diagnosis and NANDA format
should be used. The goal should be attainable in this single interaction. The description
of the nonverbal communication should include gestures, tone of voice etc. The student
should record in the nurse behavior section his/her own thoughts and feelings throughout
the interview.

The content and process of the NPR are identification of the therapeutic techniques, the
rationale for each technique, identification of nontherapeutic techniques and
identification of an alternative approach to be used in future interactions. Look for
themes in the interaction and apply theory from your text in your analysis.

Examples of therapeutic techniques to be used:

D.Offering self
E.Summarizing
F.Validating
G.Broad opening
H.General leads
I.Reflection
J.Silence
K.Focusing