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Example of process recording interview in mental health patients.

Example of process recording interview in mental health patients.

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Introduction: PROCESS RECORDING is an educational tool that access the communication skills of the students seeking certifications or degree in nursing , social work and similar courses.

Definition : process recording is a written account or verbatim recording of all that transpired, during and immediately following the nurse patient interaction.

sample :

Format for process recording

Name of patient : Mr. X

Place : Bangalore

Name of the hospital : St. Jhon Hospital

Date & time : 27/7/19, 2.00 pm

Objecrtives :

1st : to establish rapport with the patient by introducing myself through history collection .

2nd : to find out signs and symptoms of patient behaviour through question and answers

Verbal response

Non verbal response

Therapeutic communication technique

inference

Nurse

Patient

Nurse

Patient

Hello , Good morning

Hello , Morning

Looking at the patient with a smile

Looking down , turning the head to other side

Greeting

Client seems not interested in conversation

My name is Grecy , I m your primary nurse, can you tell me your name?

I am Reena Harpar

Lean forward , looking at the hand , making observation on name band

Looking at my face

Exploring

Client seems to have intact remote memory

Ok , thank you so much. ok can you tell me what is the time and date

I believe its may be 4 pm but about date i cant say

sitting strainght , listing carefully and assessing the facial expression

Looking at the open window, confused

Presenting reality

Client is disoriented about date and time

Actually its 2.15 pm, 27/7/19 . ok lets talk about your medicine. Can you tell me more about why you are not taking your medicine?

Because my husband has mixed poison in that so that I die.

Observing the patient

Patient started to become restless

probing

Clients seems to have delusion of persecution

Ok, Reena calm down , here you are safe.

Are you sure ?

Holding hands of the patient

Tightly holding the nurse’s hand

Reassuring

Patient got relaxed to some extent

Yes, So, I will conclude interview here today. You take rest now we will meet again tomorrow . do you want to tell anything else? Thanks once again. bye

Nope, thanks Grecy , bye

Got up from the chair and Wave goodbye

SMILING, waved back

Exploring

Patient looks relaxed and happy

Summary : I Ms. Grecy conducted the process recording with the patient named Mr. X as part of my duty. As the objectives were to built rapport and collect data about the signs and symptoms . during the procedure patient was cooparative . end of the session the patient found disoriented about date and time and having delusion of persecution.

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