THERAPEUTIC COMMUNICATION: PROCESS RECORDING
DEFINITION
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Therapeutic communication is an interpersonal interaction between the nurse and the client
during which the nurse focuses on the client’s specific needs to promote an effective exchange
of information. Skilled use of therapeutic communication techniques helps the nurse
understand and empathize with the client’s
Process recording is a written account of an interaction between a client and nurse. That is, a
record of the on-going interaction, the process of two people relating with each other. The
recording includes a description of the patient's nonverbal and verbal behaviors, the nurse's
response, identification of the therapeutic technique used by the nurse, and an explanation of
the nurse's evaluation and interpretation of the interaction.
PURPOSE
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Establish a therapeutic nurse-client relationship.
Identify the most important client concern at that moment (the client-centered goal).
Assess the client's perception of the problem as it unfolds; this includes detailed actions
(behaviors and messages) of the people involved and the client's thoughts and feelings about
the situation, others, and self.
Facilitate the client‘s expression of emotion.
Teach the client and the family necessary self-care skills.
MATERIALS/EQUIPMENT
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Pen
Paper
PROCEDURE
RATIONALE
Able to
Perform
(2)
Able to
Perform
with
assistance
(1)
Unable
to
perform
(0)
Assessment
1. Patient’s non-verbal behavior
a. Notice the patient's nonverbal
behavior.
b. Look at the patient's appearance.
c.. Look at the patient's body
language.
d. Look at patient’s actions.
i. How does he walk?
ii. How are his body movements?
iii. What are his motor activities?
iv. Is the patient able to establish
eye contact with you?
v. Does talking about certain
topics cause the eye contact to
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increase or decrease?
vi. Are there signs of anxiety?
e. Based on these observations,
Assess the patient's affect (or
feeling tone a reflection of
mood).
f. Make many more observations of
nonverbal behavior and include
them in your process recording.
2. Patient’s verbal behavior
a. Notice the patient's tone of voice.
b. Are the patient's conversations
appropriate to the persons he's
with and the situation he's in?
c.. Are his moods expressed
appropriately?
d. Are his thoughts and ideas
connected?
e. Does his conversation
demonstrate that he is reality oriented (that is, in touch with
reality)?
3. Nurse’s Response
a. Find yourself reflecting on your
own behavior in specific
situations.
b. Ask self why your patient
responded to you in this way or
that.
c.You may also want to know what
nonverbal cues you have to the
patient while you told the patient
that you were glad to see him.
Planning
4. Develop a short-term goal that is client
centered and that will serve as a
guideline and purpose for the
communication/session.The length of
time of any given session can vary from
10 minutes to one hour.
5. Prepare the materials/ equipment.
Implementation
6. Enter the data at the top part of the
sheet. The recording is to be made on a
meeting with your client.
7. Column One/Setting: Describe the
setting and your plans to therapeutically
approach the client at the beginning of
the session with sufficient clarity and
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detail so that the instructor will be
helped in his/her understanding of the
situation. The setting includes a
description of the physical environment,
time, position of you and the client and
any other pertinent details. The
therapeutic approach includes the
verbal and nonverbal therapeutic
communication techniques you plan to
utilize during the interaction.
8. Columns Two & Three/Verbal and NonVerbal Communication Student and
Client: The nonverbal communication of
both you and the client is as important
as the verbal communication. Identify
the nonverbal communication. Is there
congruence between the verbal and
nonverbal communication? Recording of
verbal communication should be
verbatim. If the meeting includes a
period of an activity that you participate
in with the client, record only the
beginning, the termination, and what
you consider significant material in the
remaining time.
9. Column Four/Student’s thoughts and
feelings concerning the interaction:
Describe your reactions to the
communication. What kind of emotions
did you feel and why? Were you at ease
or uncomfortable? Did you feel you had
to struggle to remain objective? Did you
feel like you could help the client? Did
you feel confident at the end of the
communication?
10. Column Five/Evaluation/Analysis of the
Interaction/include therapeutic
techniques/approach applied:
a. Your perception of the client's
feelings and behaviors
b. Defense mechanisms used by the
client
c. Client's level of insight into problems
d. Client’s Anxiety level
e. Outcomes of therapeutic techniques
used
f. Alternatives to therapeutic techniques
g. Assess the client's needs and your
ability to meet one or more of them
h. Analyze the effectiveness of the
communication to the best of your
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ability.
Evaluation
11. Evaluate client’s verbal and nonverbal
behavior and reactions.
12. Evaluate your own verbal and
nonverbal behavior and reactions.
Documentation
13. Record everything that is required in
the Process Recording sheet.
Process Recording
STUDENT’S NAME: _________________
CLIENT INITIALS: ___________________
AGE: _________
GENDER: ________
DATE: ______________
MEDICAL/SURGICAL DIAGNOSIS: ______
___________________________________
SETTING
VERBAL &
NONVERBAL
COMMUNICATION:
STUDENT
PERTINENT NSG. DX: ______________
_______________________________
SHORT TERM GOAL(S): ____________
_______________________________
VERBAL &
NONVERBAL
COMMUNICATION:
CLIENT
STUDENT’S THOUGHTS
AND FEEINGS
CONCERNING THE
INTERACTION
EVALUATION/ANALYSIS
OF THE INTERACTION
INCLUDE THERAPEUTIC
APPROACH/
TECHNIQUES
APPLIED
Remarks:_____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Grade:__________
Rating Scale:
Excellent
Very Satisfactory
Very Good
Good
Fair
Poor
:
:
:
:
:
:
96- 100%
90-95%
85-89%
80-84%
75-79%
74 & below
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Name: ______________________________________________
Year & Section: ___________
Date of Lecture Demo: ___________________________
Date of Return Demo: ___________________________
FINAL GRADE: ____________
Name of Procedure: ______________________________________________________
A. SKILLS (70%)
Communication Skills
Performance Rating
(10%)
(60%)
______________ ______________
______________ ______________
B. KNOWLEDGE (20%)
Manual
Content / Rationale
Grammar and Composition
Neatness of Handwriting
Quiz
(5%)
(2.5%)
(1.5%)
(1.0%)
(15%)
______________
______________
______________
______________
______________
(2.5%)
(2.5%)
______________ ______________
______________ ______________
(2.5%)
(2.5%)
______________ ______________
______________ ______________
C. ATTITUDE (10%)
Lecture Demo
Punctuality
Behavior
Return Demo
Punctuality
Behavior
TOTAL
______________
______________
______________
______________
______________
______________
REMARKS:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________
Lecture Demo Instructor
__________________________
Return Demo Instructor
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RLE Procedure Notes
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Paper for the Quiz
Computation:
Score X 75 + 25 = ____
No. of Items
Name: ___________________________
Date: ____________________________
CI for Return Demonstration
___________________________________
QUIZ for :
Score : __________
PROCEDURE
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