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Process Recording

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Process Recording
Interpersonal process recording

Student: _____________________ Date: _______________
Instructor: ______________________________
Unit: _East__________ Patient initials: __I.S.____ Pt. Diagnosis s/p RTK_______________________
Age: __74_____ Gender: __F______ Family/support: ____Dtr Linda (POA)____________________ Psychosocial issue:___________________
Briefly describe the goal for the interaction and the focus of the communication: Goal for interaction is to address the pt. pain, focus of the communication is on goal for pt to participate in PT/OT daily with pain controlled.

Description and effect of the setting: Setting patient room. Pt in her bed, day clothes on, R knee elevated with ice.

Verbatim account of patient's verbal and non-verbal communication | Verbatim account of nurse's verbal and non-verbal communication | Nurse's thoughts, feelings, reactions | Communication techniques utilized: therapeutic/non-therapeutic | Analysis and self evaluation | Hi, Good morning Jay Jay, I remember you. I’m so glad you are back, I had a horrible weekend? The nights here are terrible, it takes forever to get anyone to answer my light, and I can’t seem to find anyone who wants to help me, when I asked for ice last night the girl rolled her eyes as me and asked, if I was serious! It’s just awful. Actually, Heather the nurse was in here when that girl did it. The aid was the pretty little, black girl with the super long eyelashes. I bet Heather will know who she is. Oh, good. Thanks Jay Jay. (pt cell phone rings, it’s her daughter,) Pt nodded (yes) Now why don’t you sit in that chair? (pt gestured for me to sit in the chair at her bedside) 9
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