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Neosho County Community College

Mary Grimes School of Nursing


NURS 261 Mental Health Nursing

Mini Process Recording
Instructions and Example


Student Nurse:_____________________________ Date of interaction:___________________________
Group: A B C D E F
Writing A Process Recording
The purpose of a process recording is to communicate, identify, practice, and record the use of
Therapeutic communication techniques vs. having a general conversation. A Process Recording allows
the conversation to focus on specific issues and feelings the client may have. Being therapeutic does not
focus on giving advice or asking why questions, but will focus on a style of communication involving
listening, observation, clarifying, using open ended questions, seeking accurate information and being
aware of your clients belief processes and behaviors. THE PROCESS RECORDING IS A LEARNING TOOL.
The Process Recording is a written report of a verbal interaction with a client. This is a verbatim account
written by the student and is a tool for improving interpersonal communication techniques. The Process
Recording helps the student to look at the content and pattern of the interaction. The Process Recording
is not doing THERAPY but is a helping communication process. It also is not just conducting an
interview, nor is it a tool to persuade the client to reveal secrets.
HOW: The format will follow the Phases of relationship development. You will conduct a therapeutic
interaction based on a problem/ goal/outcome that your client identifies and would be willing to
discuss. This verbal interaction when written out becomes a Process Recording. From your verbal
interaction, you will identify and record:
TT: therapeutic techniques used
FW: Feeling words your client uses
DM: defense mechanisms your client uses
NTT: Non- therapeutic techniques you use
NV: non-verbal behaviors you notice your client uses and what you yourself use
ST: subjective thoughts you experienced during your interaction


Use your text book and handouts for examples.

WHAT YOU DISCUSS WITH YOUR CLIENT:
You will follow the phases of the relationship outlined below.
MINI PROCESS RECORDING
Instructions and Example

2
Ask your client if there are any concerns that they would like to discuss. Sometimes the person
does not identify a problem or concern.
Consider: What concerns or issues do they see as stressful or have difficulty coping with. Focus
can be on their coping skills or how the person handles stress.
YOUR GRADE:
Write a brief setting the scene in the Pre-orientation phase. This will include brief information about
the client and describing the environment where the interaction took place.
Identify a minimum of:
4 TTs (therapeutic techniques)
2 FWs (feeling words)
1 DM (defense mechanisms with rationale)
1 NTT (non-therapeutic technique you made and what would make it therapeutic).
NV behaviors used by the client and yourself
ST: (subjective thoughts you have)
Additionally, you will:
Write one NANDA Nursing Diagnosis
Establish one client centered outcome (goal) that can be accomplished during this interaction
Evaluate the outcome - state if met or not-met with as evidenced by
Write the students evaluation
Your ability to complete the required criteria and have continuity will be evaluated. The Process
Recording does not need to be long, try to keep it no more than 3 total pages. Word Processing is
preferred and an electronic copy will be available on Inside NC. Neatness, spelling, and legibility will be
considered in your overall grade.








MINI PROCESS RECORDING
Instructions and Example

3
Important Tips to remember:
Do not take notes while you are engaged in your therapeutic interaction - take a break if necessary.
Maintain therapeutic boundaries with the client. Avoid touching or allowing the client to touch you.
Do not isolate yourself in a private room with the client - find an area where you can maintain
confidentiality yet have access to others.
Always report to the staff and clinical instructor all threats the client may express of hurting self or
others.
Do not promise to keep secrets - between us type statements. Be honest and tell the client this.
You will address all of the /steps of the PR unless your instructor directs your otherwise.
Always report any emergency situations to the nurse and instructor immediately.
Review the examples of Process Recordings to help you with the format.
Maintain a professional approach with the client
If the client does not want to talk, contact the nurse or instructor to help you meet another client.


















MINI PROCESS RECORDING
Instructions and Example

4


Step I: Pre-Interaction Stage: This stage of the interaction process considers the students feelings as
to their ability to work with a client. You will gather information from the medical record and staff that
can be included in the Setting the Stage section.
Step 2: Orientation Stage: This is the beginning of your process recording. You are gathering
assessment information in this stage.
YOU WILL DISCUSS THE FOLLOWING USING THERAPEUTIC TECHNIQUES:
IDENTIFY YOURSELF - STATE YOUR PURPOSEIDENTIFY THE PROBLEM ISSUE YOUR CLIENT
WANTS TO DISCUSS
SET AN OUTCOME
DEVELOP A NURSING DIAGNOSIS .
During this stage you will start to develop trust and rapport, and also establish where to meet. You will
be completing a general bio/psycho/social assessment.
_________________________________________________________________________________
Step 3: Working stage: YOU WILL DISCUSS THE FOLLOWING USING THERAPEUTIC TECHIQUES:
THE MAIN FOCUS IN THIS STAGE IS TO DISCUSS THE SPECIFICS OF THE PROBLEM IDENTIFIED AND THE
OUTCOME (GOAL) SET IN THE ORIENTATION STAGE.
You will discuss specific feelings, do some teaching, help the client look at coping skills and explore the
use of new skills. This is the time to talk about the problem. You may encounter the use of defense
mechanisms, Although you may encounter inappropriate behavior, you may also encounter positive
behaviors and willingness to change. Your job is to verbally clarify and guide your clients responses in
order to keep the conversation going.
_____________________________________________________________________________________
Step 4: Termination stage: YOU WILL DISCUSS THE FOLLOWING USING THERAPEUTIC TECHNIQUES.
THE MAIN FOCUS OF THIS STEP IS TO ASSESS AND SUMMARIZE WITH THE CLIENT WHAT WAS
DISCUSSED IN STEPS 2 AND 3. This can include progress made, and how the client can better cope with
the problem or concern. You may also assess the clients ability or willingness to try new coping
strategies.
SHOW CLOSURE OF THE INTERACTION. (How did you end the interaction - use verbatim words)
EVALUATE THE OUTCOME WHICH WAS SET. Identify positive outcomes, the need for ongoing
assessment, or discharge planning if appropriate. If not met, what would you change?
_____________________________________________________________________________________



MINI PROCESS RECORDING
Instructions and Example

5

Step #1 Preorientation:
Setting the Stage: Admission Date: 7/10/10 Describe environment: Day Hall.
Sat at the end of the day hall to decrease noise and stimuli.
What was the clients behavior that required admission and/or what requires the person to remain at the facility:
(briefly describe):
Step #2 ORIENTATION
Nurse statements & non-
verbal behavior

Clients statements & non-
verbal behavior

Subjective thoughts





Interpretation of therapeutic
techniques



Hello, who are you?


Good Morning ---- I
am_______ a student.

Oh, youre a student.
(frowns, then smiles)


I hope this goes well. He
looks okay.


TT: Giving recognition

I would like to spend some
time talking with you today.
(smile, eye contact)

What about? I cant say too
much, but I can tell you some
things.

TT: Offering self

We can talk about any of
your concerns. (sit at table
with client)

Well, its the medicine,
always the medicine. (waves
his hands in the air)

This may be hard, he
seems like he will talk, but
who knows?


You sound concerned about
your medication. Tell me
more.

I dont like to take my
medicine. I get upset when
people tell me to take it, It
made me sleepy. (shakes
head back and forth). I am 22
years old you know.

FW: Like, upset

TT: Making observation

TT: Offering general lead


NANDA NURSING DX: Non-compliance with medication regimen r/t refusing medication based on side effect of
increased sleepiness and feeling like a ex

Client centered outcome (goal) to be achieved: Client will verbalize one benefit for taking medication by 1100
today. ()


MINI PROCESS RECORDING
Instructions and Example

6
Working stage: Step 3
Nurse statements & non-
verbal behavior
Clients statements & non-
verbal behaviors
Subjective thoughts

Interpretation of
therapeutic techniques

When people tell you to take
the medication, it upsets you.


Yes, I should be able to make
my own decisions.

TT: Restating

I hear you saying you want to
make your own decisions.
(look down, move back in
chair)

Yes.


What happens when others
tell you to take your
medicine?

Well, I get mad. My Father
does that all the time. I hit
him, but that was wrong and
Im sorry I did that. (looks
away) He tries to run my life,
but I dont want to talk
about him. I need to talk
about my medicine with you,
right? (smiles & leans back).

I wonder if it makes him
anxious. I think he needs to
talk about his anger.



Now, I wonder if he is testing
me.

DM: Suppression: (doesnt
want to talk about his
Father)

FW: Mad, Im sorry
DM: Projection:
Blaming My Father
does that all the time

If you want to talk about your
medication, thats fine. Why
did you stop taking your
medication?


The medicine slows me down
& I cant do my work. It
makes me sleepy. I like to
feel energy, I want to keep
moving.

Is this part of his symptoms?

NTT: Probing: Asking
several questions & why
Better to say: Yes, tell me
more about your
medication. OR: What are
some of the reasons you
stopped taking your
medication?

It slows you down? (look at
him)

Yeah. Like a zombie. My Doc
has changed my medication
and I am not as sleepy now. I
like that I can do something.

I wonder if he will stay on his
medication?

TT: restating


FW: feel like a zombie

So, is this something you see
as positive?

I guess so. I just want to
make my own decisions. I
decided to take my meds.








MINI PROCESS RECORDING
Instructions and Example

7
Working stag: Step 3 continued


They tell me I may go home
soon so I had better work
with them. That means
taking my medication

Wow, something positive.




TT: Verbalizing the implied.

So, your plans are to
continue taking your
medication after discharge.
Who knows. Yes, I plan to go
back to work at McDonalds.
I need to do my job well.

Is there some doubt about
taking the medication?


It sounds like you have
decided your medications
help you to do your work
better.

Yeah, I can think and do my
work better and follow
orders. (smiles)


(looking at my watch)
Well, its about noon. Its
time for me to leave.

Yeah, its time to go. I am off
to take my meds.(smiles,
leans forward, loud voice)


NTT: Looking at my watch.
May imply I am anxious to
leave. Also, I changed the
topic abruptly. Better to say
I see people lining up, is it
time for lunch?

Step 4 TERMINATION
Nurse statements & non-
verbal behaviors
Clients statements & non-
verbal behavior
Subjective thoughts Interpretation of
therapeutic techniques

I have enjoyed talking with
you this morning.

Yeah, I liked talking with
you too.

FW: liked

We talked about your
medication and how you
arent feeling so sleepy now
and how it helps you to
concentrate on your job.
Also, how important it is to
you to make your own
decision. (make eye contact)






Right. I am 22 years old.

Well, made it through
without him getting upset
with me.


TT: summarizing

Thank you, have a good day.

You too.


(stand up)

(smiles and walks over to
the medication room.






MINI PROCESS RECORDING
Instructions and Example

8
Outcome evaluation: Met. He stated that the medication he is on now doesnt make him as sleepy. Also,
suggested that he needed the medication to help him do his work at McDonalds by increasing his ability to do his
work and to concentrate.
Student Evaluation: I was really anxious and I asked the why question & probed. I need to work on my anxiety. I
am close to this clients age and I need to think about being therapeutic. It would be easy to just talk about every
day things, like music. I think the interaction went pretty well, I was able to use some therapeutic techniques &
managed some teaching, but it is hard to think of the right thing to say. I am not sure if he will stay on his
medication once he leaves so I think he needs continued education and reinforcement regarding his medication.
Also, I think there are unresolved issues with his Father that he needs to work on. I wonder where he plans to live
once he leaves. This could be important.


PROCESS RECORDING GRADE SHEET
CRITERIA POINT VALUE STUDENT GRADE
Setting the stage 2 points 2
Nurse 6 points 6
Client 4 points 4
Subjective Thoughts 2 points 2
Therapeutic Techniques (4) 2 points each
8 points total
8
Non-verbal for nurse & client 1 point each
2 points total
2
Clients feeling words (2) 1 point each
2 points total
2
Non-therapeutic techniques with
Alternative
2 points 2
Defense Mechanism with rationale 2 points 2
Nanda Nursing DX 2 points 2
Client centered outcome (goal) 2 points 2
Outcome (goal) evaluation 2 points 2
Student evaluation 2 points 2
Neatness, legibility, spelling 2 points 2
40 POINTS POSSIBLE TOTAL POINTS 40
% _100____________________
Instructor Comments: You recognized where you can improve and worked to encourage the client to verbalize his
concerns. Also, were able to look at future concerns for the client. Continue to work on developing therapeutic
communication skills.