Process Recording (Sample)

Source: (https://nursinghelp.wordpress.com/med-surg/process-recording)

Client Diagnosis: Bipolar Disorder, suicidal ideation, suicides attempts

History RT Diagnosis; Onset: 8 suicide attempts, anhedonia, anergia, poor sleep, inability to function
Hopelessness, helplessness, no violence toward others.
Hx: HIV(+), COPD.
Duration & Prior Treatment:

Nurse Communication Client Communication Nurse’s Thoughts & Feelings Related Analysis of the Effectiveness,
(Verbal & Non Verbal) (Verbal & Non Verbal) to the Interaction Technique Name & Rationale
1. Hello… Hello… I had the feeling that he wanted to talk with Greeting the patient:
someone.
(Establishing eye contact while (Looking me directly with a facial It is necessary in order to have an
approaching in a friendly manner) expression that denotes interest.) appropriate start for the conversation.

2. My name is Cristina, I’m Nursing Yes, not problem. I felt well when he answered and approved Introducing oneself and establishing a
student at DMCCF, and I would talking with me. contract:
like to talk with you for a moment. (The client has a flat emotional but
Would you like to speak with me? accepting expression in his face. He is It should be done when meeting the client
calm and has a soft speech) for the first time in order to have an
(Leaning forward the patient, with open appropriate start for a therapeutic
posture) communication.

3. Ok, thank you. And your name My name is J.K. Thinking about how to start the Identifying the patient / Giving
is…? conversation and taking him straight to the recognition:
(He shows relax posture and open attitude, point without being too invasive.
( I took a sit next to him at his right side) well groomed appearance) Shows to the client that the nurse wants to
recognize him as an individual, as a
person.

4. How are you today? I’m ok… Trying to initiate the conversation. Broad opening question:

active (He seems not very convinced of that) Gives the client the lead in the interaction,
and it may stimulate him to take the
(Leaning forward, making eye contact) initiative.
 5. Would you like to tell me a little The reason why I’m here is because… you Satisfied that he understood my question Broad opening question:
about yourself, what brought you know… I have had several suicidal and he was willing to open himself to the
here or what is happening to you if attempts in my life, and last week I knew I conversation. Gives the client the lead in the interaction,
you want to share it with me? was going to try it again. and it may stimulate him to take the
initiative.
(Using SOLER technique of active listening)
I wanted to kill myself, but I recognize the
symptoms and I came here for help before
I actually did it.

I came voluntary here.

6. Tell me little bit more… You said Yes, it is what I wanted to do. I feel really I wished not having to ask that question, it Restating:
you wanted to kill yourself? sad, there is something in my mind, there is really sad.
is depression, something that I cannot The restatement encourages the client to
(Active listening) control or get rid of it, and I cannot handle I knew exactly what he was talking about, continue, and let the client know that he or
it anymore. I’m really tired. It hurts my because I was very closed to a person in she communicated the idea effectively.
mind, is pain, is an uncontrollable pain that my life with the same problem.
I feel, and I don’t know why I feel this way.

(His sadness and powerless is evident in

his face)

7. How were you planning to kill Taking my bottle of meds at one time. Trying to know more about the situation. Exploring:
yourself?
(The sadness continues) Allows the nurse to gather more
(Active listening) information regarding important topics
mentioned by the client.

8. You say you tried it before to kill In November, 2 months ago. I took 90 pills. I was feeling very sorry for him. He had so Placing event in time or
yourself? much going on in his life. sequence:
It happen to me because I have Bipolar
When was the previous time that you had Disorder. I’m also HIV(+). Putting events in proper sequence helps
also tried it? both the nurse and client to see them in
I had being suffering from Bipolar since perspective.
(Active listening ) 1982 and I was diagnosed with HIV 8
years ago. The nurse may gain information about
recurrent patterns or themes in the client’s
(Very cooperative and providing detailed behaviors.
 information about himself)
9. I imagine how hard should be for Yes it is, and I cannot explain myself why I I’m feeling sad, and thinking how can I Empathy:
you to have this two diseases. have this depression and this pain. help him to alleviate his pain.
When empathetic, the nurse is
(Active listening) I cannot tolerate it any more. I live with my I believe it is too much suffering for an nonjudgmental, sensitive, open, and
partner and I cannot talk with him about individual having these two diseases. capable of imagining another person’s
this. experience.

(Confused, frustrated, sad)

10. Can you explain it little bit more? He is very supportive with me, and I don’t I’m realizing his support system is failing. Seeking clarification:
What it’s the reason why you want to talk with him because I don’t want It’s hard to understand the refusing of
cannot speak with him? to hurt him. It is enough with my pain. I seeking help in his close family and It helps the nurse to avoid making
don’t want to pass him my problems. keeping all to himself. assumptions that understanding has
(Active listening) occurred when it has not.
(Confused and depressed)

11. But what do you think he would But the thing is. What you would do if you His depressive disease makes him Presenting reality:
prefer? Help you if you open to have to decide between hurt yourself and disoriented about the potential
him, or see you that you took your hurt the person you love? consequences of self-injury could produce Clarifying misconceptions that client may
life. to his significant others. be expressing.
(Poor judgment)
(Active listening techniques) Intents to indicate an alternate line of
thought for the client to consider.

12. It is a difficult answer but … Don’t Yes I know but is something very difficult He is having poor judgment about the Non-therapeutic:
you think that hurting yourself and to explain, the pain inside my brain, the significance of hurting other person or
taking your life, is a way of hurt him depression, the loneliness has such himself. It could be non therapeutic because I’m
too? dimension that is very difficult to think rejecting and refusing to consider or
clear. showing contempt for the client’s ideas or
(Small frown) behaviors.
(Frustrated, sad)
I’m also probing or persistent questioning
the client.
 13. Does your partner has HIV too? Yes, he has. We both contracted it but we Feeling sorry for both now. Non-therapeutic:
never knew how we got it.
(Non judgmental expression) I’m Introducing an unrelated topic or
(The depression seems to be bothering changing the subject.
him much more than the HIV disease)
The topic could be a little related but I’m
losing the focus about my patient. The fact
of knowing if his partner has or not HIV it
doesn’t contribute to identify the patient’s
feelings or problems.

14. Are you taking medicines to control Yes, I’m taking 22 pills twice at day. I think 44 pills at day is something that Exploring:
the HIV and the Bipolar Disorder? even myself I wouldn’t even tolerate.
But other problem is that the pills are good Allows the nurse to gather more
( Light surprised expression after the for certain time and after a period they are Thinking about what are the positives information regarding important topics
client’s answer) not effective anymore. things in his life and ways to help him to mentioned by the client.
find the support he needs.
(Continues willing to give information
about him)

15. I know. It happens because your Yes he does. I believed he has loneliness and I am Giving information:
body and metabolism get used to maybe helping him in some way to escape
them and the meds turn not being I would like also here at the hospital let us from it. Increases the client’s knowledge about a
as much effective as they were talk in groups, to have a way to share each topic, let the client know what to expect,
before. It is something that your other our problems. It is necessary to have and builds trust with the client.
doctor needs to address therapy groups that can help for our
periodically to ensure you get the situation.
best option available.
(Showing hopeful interest on being
(Trying to be explicative) accomplished his desire)

16. Have you ever participated in Yes, I was member of a therapy group for I realize that that the patient is willing to Encouraging comparison:
therapy groups in the past and that many years, but now here we need talk and he trusts me.
has helped you with your someone who listens to us. It is why we The client benefits from making these
depression? are here. If nobody talks or listens to us is comparisons because he or he might recall
the same that being at home. past coping strategies that were effective
(Active listening) or remember that he has survived a similar
(Increased interest in talking about it) situation.
 17. I understand what you mean. We Ok thanks. Trying to explain that people in this Accepting:
do have meetings groups here, hospital is willing to help him when he
and you will have the opportunity to (Showing doubt of the possibility of being needs it. An accepting response indicates the nurse
talk and express your feelings. But helped in the hospital) has heard and followed the train of
always remember you have the I believe that he really feels lonely and thought. It does not indicate agreement but
right to call the nurse anytime you desperate for communicating with is nonjudgmental.
need it and ask help or something someone willing to listen him.
else you need. Giving information:

(Trying to be explicative) Increases the client’s knowledge about a

topic, let the client know what to expect,
and builds trust with the client.

18. Do you believe that maybe I don’t know if it would relieve 100% from Thinking in orienting the client to find a Encouraging expression:
participating in therapy groups can my depression but it may help something. support system that helps him to resolve
help you to deal with your his emotional problem. Asking the client to consider people and
problems, as it was in the past? (Slightly hopeful, but not convinced) events in light of his own values, the nurse
encourages the client to make his own
(Active listening ) appraisal of the situation.

19. Tell me what activities you No I don’t work, I have disability. Thinking also that having a passive life Exploring:
normally do? Do you work? style doesn’t help to his disease.
(Flat expression) Allows the nurse to gather more
(Active listening ) information regarding important topics
mentioned by the client.

20. I see… and the fact that you don’t Well, life is very difficult today but that is Trying to find more seasons that may Non therapeutic:
work, can that situation also be not affecting me so much with my influence in his depression.
contributing with economic depression. This question could be done instead a like:
problems you may have? Does this situation contribute to your
(Sadness and flat expression) stress? Because some people don’t like to
Since life is very difficult today for speak about their economic problems, and
everybody. It is that situation also affecting they actually can deny a fact that is real,
you in your depression? without giving more information.

(Trying not being too invasive)

 21. And, what about doing activities to Yes, it could help for moments but the Feeling that he wanted to find help in a Encouraging expression:
help you distract yourself from your depression always comes back. therapeutic group as he did in the past.
depression? Asking the client to consider people and
(The sadness expression continues) events in light of his own values, the nurse
(Active listening) encourages the client to make his own
appraisal of the situation.

22. I believe that the fact that you Yes, I know. I wanted to remark the positives aspects Making observation:
recognized your suicidal thinking about himself, and his accomplishments to
and decide to come to the hospital (Hopeless) increase his self-esteem. It verbalizes what the nurse perceives
seeking help it is a good point, and when the client cannot verbalize or make
a positive alternative you chose themselves understood.
instead of harming yourself. It is
something that you would have to Formulating a plan of action:
implement in the future if it ever
happens again. It may be helpful for the client to plan in
advance what he or she might do in future
( Showing a positive attitude) similar situations.

23. You are doing a big progress in Thank you for have listened to me. I think that it is necessary help him to Summarizing:
seeking help, and coming here visualize the positive side of his situation in
voluntary to the hospital. I wish you (Grateful expression) order to give him some hope and Brings out the important points of the
a soon relief of your medical encouragement. discussion, increase awareness and
problems, and the ability to I think I have to take my medicines now… provides a sense of closure at the
continue increasing strength in completion of each discussion for both
dealing with them. (He sudden remembers something…) client and nurse.

(Trying to give some hope)

24. Thanks to you for share with me I’m going to get my medicines. It was a good conversation. I feel he Closing of the interview
your concerns. wanted to talk and it may help him.
(Standing up)
(Smiling, standing up)