PROCESS RECORDING ➢ Purpose:

- Technique : record the verbal interaction or written ○ to reflectively examine communication skills
record of entire commu pattern between nurse ○ Helps the patient to socialize
and pt ○ Develop therapeutic communication with client
- Assessment tool to explore thought process/ ○ Gain cooperation and Confidence from patient
mental issues
➢ Content:
➢ Communication - process: exchange info Student Nurse’s Resident’s Therapeutic / Defense Analysis of the
➢ Context - envi where commu occurs (time, physica, social, Verbal/And Verbal/And Non- Mechanism Interaction
Nonverbal Cues Nonverbal Cues therapeutic
emotional and cultural environment), situation or Communicatio
circumstances: clarifies meaning of content of message n Techniques

➢ Content - literal words THE NURSE THE RESIDENT ● Must be ● Indicate and ● Write entire thera
SHOULD: SHOULD: observed at explain commu directed
➢ Process - nonverbal messages ● Aware that therap ● Assess pt’s all times what Def to the PT
➢ Congruent Message - process & content (V/N) agree commu is Two- nonverbal ● Clarification mechanism ● State convo made
sided event behavior must be was used and have not
➢ Incongruent message - process & content (V/N) disagree ● Have self- (speaks more observed by PT been said
awareness loudly than when N during ● Comment on what
➢ Therapeutic commu - nurse focuses on client’s needs to ● Remember his verbal), body cannot interaction flow of beh
response to pt language, understand means and
promote eff exchange of info verbalizations conversation & the PT interpretation
➢ Active observation - watching speaker’s nonverbal action as ● Take note of his expressed ● Make use of ● Suggestions of
own moods are thera tech to other thera
he communicates nonverbal/verbal appropriate minimize commu
cues: should be ● Notice appearance blocked ● Interpretation of
➢ Proxemics - study of distance zones during commu objectively of pt commu the thera
○ Intimate zone: 0-18 inches, for parents with described ● Check if pt
maintain eye
● Always allow PT
to verbalize
commu inv beh
of N & PT t odev
young children, who mutually desire personal contact, check feelings ways of looking
signs of anxiety at events and
contact, or whispering. Invasion = threatening & and restlessness USED BY THE next
● Take note of pt’s NURSE interventions
produces anxiety (N TAKES VITAL SIGNS) actual words
○ Personal Zone: 18-36 inches, between family and ● Notice if ideas re
connected or
friends ( not
● Take note if
○ Social Zone: 4-12 feet, in social, work, and conversation is
based on reality
business settings and awareness
○ Public Zone: 12-25 feet, between a speaker and an
audience, small groups, informal functions.

➢ Guidelines
○ Physical setting should be calm and quiet
environment (Interview rooms or bedside, if
separate room is not available)
○ A recording device is used that will help in
reviewing the session if needed (CDU: jotdown
notebook)
○ Obtaining consent for the patient for recording the
information
○ Patient overall response towards the interaction to
be recorded
○ Record verbal and non-verbal communications
accurately
○ Communicate effectively through using various
therapeutic communication technique
○ Maintaining confidentiality of information
■ Students and field supervisors should
ensure that agency documents and
recording are de-identified in accordance
with HIPAA regulations
■ In settings which are not covered by Health
Insurance Portability and Accountability Act
(HIPAA), students are expected to protect
client/consumer/participant confidentiality in
accordance with professional practice
standards, including but not necessarily
limited to the following:
● Delete any reference to the agency
name and/or staff names
● Change names (first and last) and
initials.
● Delete any reference to address or
any information specifying
geographical area, such as street
names, businesses, or hospitals
● Delete any information that would
enable identification of clients, other
professionals, agencies, or agency
personnel.
● Use email and other electronic means
to send recordings/analyses between
the student and field supervisor (and
the student and field liaison) with
attention to the privacy of the people
about whom the document is written
(Process Recording Guidelines
Handbook, 2018)
○ Nurses should be truthful in recording what’s said
and did by self and by the patient
○ Nurses own thoughts and feelings should be
recorded separately after writing the interaction
process
○ Each process recording should be concluded with a
summary
➢ Nursing Responsibilities
Before: After:
1. Obtain verbal consent from the patient for the possibility of 1. Documentation of the session. The nurse may want to state
cassette recording. why he/she did or said a particular thing or why he/she
2. Develop a short-term goal that is client centered and that will neglected to do or say something during the session.
serve as a guideline and purpose for the 2. The nurse may want to suggest another therapeutic action
communication/session. that might have been more helpful than the one chosen.
3. Set a calm environment for the patient
➢ Format
During: Cebu Doctors’ University
College of Nursing
1. Record the conversation verbal time. Mandaue City
2. Present the identification data and the complaint.
3. Establish rapport with the patient. Biodata
Resident’s Initials Age: Sex:
4. Written process recording may begin during the interview. Date of Admission: Physician’s Initials:
5. Notice the patient's nonverbal behavior, because it often
speaks so much more loudly than the patient's actual words PROCESS RECORDING NO.
I. OBJECTIVES
such as appearance and body language. Specific Objectives:
6. Consider the actual conversation with the patient. For
example, the tone of voice if he or she speaks softly or harshly. II. Setting of Interaction
A. Date
As well as the flow of the conversation, expression of their B. Time and duration:
moods and comprehension of the conversation. C. Palace
7. Examine the patient’s behavioral reaction to stimuli in the D. Drawing
III. Assessment
environment as these influences can include such things as rules Appearance / Behavior/ Communication / Implication
and regulations, punishments or rewards for behavior, and very
Student Resident’s Therapeutic / Defense Analysis of the
importantly, the verbal and nonverbal behavior of the nurse. Nurse’s Verbal/And Non-therapeutic Mechanism Interaction
Verbal/And Nonverbal Communication
8. Use therapeutic techniques while interacting with the patient Nonverbal Cues Techniques
such as asking for clarification in cases when the patient speaks Cues
in a way that is illogical and confusing.
IV. Evaluation
 ★ Therapeutic Communication Therapeutic Commu Definition
definition: Tech
- the nurse uses personal attributes and clinical techniques while
1. Active
working with the client, & considers privacy and respect of listening
boundaries.
- aims to establish a relationship with the client in order to be 2. Broad Encourage PT w/ch topic to discuss first
Openings Look at others, keep good eye contact
able to identify his/her most important needs, clarify the area of
Ask appropriate questions
conflict and/or anxiety and facilitate expression of emotions or Do not interrupt
feelings. Do not change the subject Express emotions
Types with control Responsively listen
● Verbal communication 3. Restating repeating main thought that was shared by
● Non-verbal communication or paralinguistic cues. This includes all client
the noises and extra speech sounds (example: tone of voice, pitch,
nervous coughing) V. Clarification Used when N does not understand the PT, put
unclear thoughts of PT
○ Action cues - these are body movements and gestures
○ Object cues - dress, furnishings and possessions. It speaks VI. Reflection Directing back the client’s ideas, feelings,
something about the speaker’s feelings. questions and content.
○ Space - provides cue to the nature of the relationship between
VII. Humor Give spice= not make too serious & boring
two people. Give encouragement
○ Touch - laying hands on the body of an ill person for the purpose
of therapeutically comforting him/her. This type is the most VIII. Informing Skill of information sharing
personal and involves both space and action.
IX. Focusing statements that help the patient expand on a
Characteristics topic of importance
➢ Genuineness: open, honest, sincere, actively inv in rel
➢ Respect: one knows the other person’s boundaries and X. Theme identification of underlying issues or problems
Identification experienced by the client that emerge
respects it. repeatedly during the course of the nurse-client
➢ Empathy understanding: ability to relate in the life of relationship
another person to accurately perceive his/her current feelings
XI. Silence let the client further express his/her feelings
and their meanings.
and thoughts without interruption
➢ Concreteness: uses specific and understandable
terminology especially when discussing the client’s feelings, XII. Suggesting Presentation of alternative ideas for the client’s
consideration relating to Problem solving
experience and behavior. This avoids vagueness and ambiguity.
★ Non-therapeutic Communication
 unconscious; telling the client the
- Involves various words, phrases, actions, and tones that make meaning of his or her experience
a patient feel uncomfortable, increase their stress, and worse
12. Introducing an - changing the subject
their overall mental, and perhaps even physical, well-being. unrelated topic
- These responses cut off communication and make it more
difficult for the interaction to continue. 13. Making - offering meaningless cliches or trite
stereotyped comments
comments
Therapeutic Commu Definition
Tech 14. Probing - persistent questioning of the client

1. Advising - telling the client what to do 15. Reassuring - indicating there is no reason for anxiety
or other feelings of discomfort
2. Agreeing - indicating accord with the client
16. Rejecting - refusing to consider or showing
contempt for the client’s ideas or
3. Belittling - misjudging the degree of the client’s behaviors
feelings expressed discomfort
17. Requesting an - asking the client to provide reasons for
4. Challenging - demanding proof from the client explanation thoughts, feelings, behaviors, and
events
5. Defending - attempting to protect someone or
something from verbal attack . 18. Testing - appraising the client’s degree of insight

6. Disagreeing - opposing the client’s ideas 19. Using denial - refusing to admit that a problem exists

7. Disapproving - denouncing the client’s behavior or

ideas

8. Giving - sanctioning the client’s behavior or

approval ideas

9. Giving literal - responding to a figurative comment as

responses though it were a statement of fact

10. Indicating the - attributing the source of thoughts,

existence of an feelings, and behaviors to others or to
external source outside influences.

11. Interpreting - asking to make conscious that which is

★ Phases of N-C Relationship
 PHASES DEF TASK MAJOR TAKS

PRE-ORIENTATION - Nurse is assigned Planning for Develop self-

to a pt and feels 1st interaction awareness
“Focus on nurse,prep, anxiety Data gathering
planning interaction,
- Prep phase
self-awareness”
- PT is excluded

ORIENTATION - N & PT meets, Building Develop mutually

and interacts rapport, asses acceptable
“Getting to know, - “Getting to know” and contract
rapport, acceptable formulation of
contract”
nursing
diagnosis

WORKING - Longest and most Planning & Identification and

productive implementation resolution of PT’s
“Longest, productive, - Highly indivi and problem
structured,planning & more structure
imple, resolution”
than orientation

TERMINATION - Gradual weaning Evaluation Assist PT to review

process what has been
“Weaning, mutually - Should be mutually learned and apply
agreed, eval, review agreed it to relationship
and apply learning”
- Inv anxiety, fear with others
and loss

SAMPLE