Chippewa Valley Technical College

Nursing Fundamentals
PROCESS RECORDING INSTRUCTIONS
Definition: A process recording is a word for word account of a conversation and incudes t!e non"
ver#a co$$unication of t!e nurse and t!e patient% It is a $et!od of evauating t!e &uait' of 'our
t!erapeutic co$$unication s(is so t!at 'ou can t!en i$prove t!e$% )ou wi #e doing a process
recording at eac! eve of t!e nursing progra$* wit! additiona re&uire$ents as 'ou advance in t!e
curricuu$%
ESSENTIA+ E+E,ENTS:
I. PRE-INTERACTIN
!ac"ground data# a paragraph descri$ing what $rought the client into the %acility and
$rie%ly how their situation has $een since then
&oal# this should $e a clear statement that is a' speci%ic (a$le to $e clearly )iewed as met
or not met'* $' client $ased (it is something the client percei)es as an issue* not the nurse*
and c' something that is relati)ely simple and a$le to $e dealt with in a short period o%
time.
II. Nurse+Client Interaction in Three-Column Format##
Record t!e actua conversation in a t!ree cou$n for$at% One cou$n is for t!e Student Nurse-s
ver#a and non"ver#a co$$unication% One cou$n is for t!e patient-s ver#a and non"ver#a
co$$unication% T!e fina cou$n is for t!e ana'sis of t!e interaction% T!e ana'sis section s!oud
#e t!e argest of t!e sections* and s!oud #e co$peted A.TER t!e interaction is co$peted%
ANA+)SIS Section:
T!e ana'sis section is t!e $ost i$portant section of t!e paper% It is not e/pected t!at 'ou
!ave a perfect conversation t!at $eets a of t!e e$otiona0ps'c!oogica aspects of t!e
cient% 1!at is i$portant is t!at 'ou understand w!at 'ou coud !ave done to $a(e t!e
conversation $ore $eaningfu and w!at 'ou are doing to eit!er encourage or #oc(
t!erapeutic co$$unication* Ana'sis $eans to oo( critica' at w!at occurred and use t!is
infor$ation to see w!at c!anges woud $a(e it #etter%
CO,PONENTS TO INC+UDE IN T2E ANA+)SIS CO+U,N:
The Introductory* ,or"ing and Ending Phases# should $e clearly identi%ied.
Identi%y attending+responding s"ills# this includes all o% the things that you did to ma"e the client
trust you (i.e. sitting at eye le)el* pro)iding pri)acy* etc-'* and all o% the di%%erent types o%
responding s"ills that you used to try to encourage the con)ersation (i.e. open ended .uestions*
silence* restatement* etc-'
Identi%y cues# what cues ()er$al and non-)er$al' did the client gi)e that made you respond the
way you did* as" the .uestions that you did* or use the non-)er$al communication that you did/
Identi%y rationale# ,hat were you thin"ing or %eeling that made you respond to the client the way
you did/ ,hat did you hope to accomplish $y your responses to the client/ ,hy did you ma"e a
certain statement/
Identi%y $loc"s+alternati)e responses# 0id you say or do something that created a $loc" in the
%low o% the con)ersation/ I% you could go $ac" and change any o% your responses* what would
you do di%%erently/ ,hat would you say/ Actual statements+ alternati)es should $e written. ,ere
there other )aria$les within the en)ironment (within or outside o% your control' that limited the
therapeutic interaction in some way/
III% Sef"Evauation Section:
At t!e concusion of t!e interaction* 'ou wi refect on t!e t!erapeutic process% .or eac! of t!e
sections in t!e sef"evauation* write a paragrap! addressing eac! area% Critica' and carefu' oo(
at !ow !epfu t!e conversation was to t!e cient* and !ow t!erapeutic t!e conversation was% 2ow
woud 'ou fee if 'ou were t!e cient3 2ow did 'ou fee as 'ou went t!roug! t!e interaction and after
reviewing it after t!e fact3
)erall Impression# ,rite a paragraph that critically loo"s at how therapeutic the con)ersation
was* and how e%%ecti)ely you assisted the client in achie)ing his+her goal. 0id you use a )ariety o%
therapeutic techni.ues/ 0id you consciously try to thin" a$out the techni.ues you were using and
what you were trying to accomplish $y use o% the techni.ues/
E%%ecti)eness o% Interaction# 0id you meet your stated goal with this interaction/
1trengths# ,hat were some o% your strengths in communication in this interaction/ 2ist a %ew
therapeutic techni.ues you used that wor"ed well.
Identi%y areas needing %urther impro)ement# Critically e)aluate your interaction and identi%y
things that you did that detracted %rom the con)ersation. Include non)er$al and )er$al $arriers to
the interaction with suggestions a$out what you %eel you could to wor" on in the %uture to $e o%
more help to your clients.
A 4RIE. E5A,P+E: This is deli$erately $rie% and lac"s in%ormation that should $e included. It is
merely an e3ample o% )arious aspects o% a process recording.
,%P% is an 67 'ear"od w!o was ad$itted for #iatera (nee repace$ents% S!e is to #e disc!arged
fro$ t!e !ospita toda'% S!e is to #e ad$itted for a s!ort ti$e to a nursing !o$e for P!'sica
and Occupationa T!erap'% S!e is upset a#out going to t!e nursing !o$e%
GOA+: To aow ,%P% to e/press !er feeings a#out going to a nursing !o$e* and to assist !er to
#egin to wor( t!roug! so$e of t!e issues t!at $a' #e causing negative feeings%
PATIENT NURSE ANA+)SIS
&ood morning (down cast eyes*
sad tone o% )oice'
,ell* yes* I am. I am going to a
nursing home today. (watery
eyes* wringing hands4
emphasi5ed nursing home'
6es* I "now* $ut I still don7t li"e
it. (loo"ing sad* loo"s down'
I miss my home and I won7t see
my dog* 1adie. (eyes tear%ul'
h yes8
9y son can do that. I really miss
1adie. (%ace $ecomes more
animated'
I am going to tal" to my son
a$out this. I loo" %orward to
seeing 1adie* and I won7t $e there
that long. (hope in her )oice'
&ood morning* 9. :ow are you
%eeling/
6ou sound sad (sits at eye le)el
close to client'
6ou will $e a$le to continue PT
so that you will $e a$le to ta"e
care o% yoursel% at home.
,hat in particular ma"es you
unhappy a$out going there/
(leans in closer'
6ou miss 1adie/ (touched her
arm* and le%t my hand there %or a
%ew seconds'
9ost nursing homes do allow pet
)isits. Could your %amily $ring
1adie %or )isits/
The sun is warm. 6ou could )isit
with her outdoors too.
I had pre)iously introduced
mysel%. Open ended state$ent
1or(ing p!ase8 Refecting. I
noticed how sad she loo"ed and
that her )oices also con)eyed this
message to me. I was hoping that
she would tell me how she was
%eeling* and I re%lected on what I
was seeing.
4oc(% I should ha)e encouraged
her to tal" a$out her %eelings. I
should ha)e said* ;This upsets
you.<
.ocusing in to help her loo" at an
area o% concern. 9o)ing in
closer to demonstrate my desire
to $e there.
9aidating% I could identi%y with
this. I too" the cue that this was
something important to her. I
noticed the picture o% her dog in
her room and had commented on
it earlier in the day.
Providing infor$ation and
support% I "new her %amily had
$een in to see her e)ery day* and
she spo"e highly o% them.
Reinforcing support% I was
opening up some options %or her
to see that she could $e with her
dog sometimes.
9aidating% Can see her
e3pression and non)er$als are
6es
6ou %eel $etter a$out going/
I7ll $e lea)ing now* $ut I will $e
$ac" in an hour. ,e can tal"
again then i% you would li"e.
telling me this message.
Ter$ination% I am letting her
"now o% my concern and
willingness to tal" to her.
Overa I$pression: I fee i(e I did a good :o# of aowing !er to open up a#out !ow s!e fees a#out
going to t!e nursing !o$e and I t!in( t!at !eping !er see t!at Sadie coud sti co$e to visit reieved
so$e of !er an/iet'%
Effectiveness of interaction: T!e goa was $et to an e/tent% 1e on' ta(ed a#out one of !er
concerns a#out going to t!e nursing !o$e% T!ere were pro#a#' ot!er issues t!at s!e !as too%
Strengt!s: I fee t!at I conve'ed caring #' $' p!'sica presence and gestures of concern% Touc! was
ver' effective in conve'ing caring and focusing see$ed to !ep !er see w!at specific issues s!e was
rea' sad a#out%
Areas of .urt!er I$prove$ent Needed: I coud !ave seen if t!ere were ot!er t!oug!ts and feeings
t!at s!e coud identif' a#out w!' s!e was depressed a#out going to t!e nursing !o$e% I need to oo(
$ore !oistica' at t!e situation% I was nervous and so atc!ed on to t!e first and on' t!ing t!at was
$a(ing !er uneas' a#out going to t!e nursing !o$e% I need to not oo( for eas' soutions* #ut oo( at
t!e #ig picture and !ep t!e cient to identif' t!ose issues t!at are i$portant to !er0!i$%