Chippewa Valley Technical College
Nursing Fundamentals
PROCESS RECORDING INSTRUCTIONS
Definition: A process recording is a word for word account of a conversation and includes the nonverbal communication of the nurse and the patient. It is a method of evaluating the quality of your
therapeutic communication skills so that you can then improve them. You will be doing a process
recording at each level of the nursing program, with additional requirements as you advance in the
curriculum.
ESSENTIAL ELEMENTS:
I.
PRE-INTERACTION
 Background data: a paragraph describing what brought the client into the facility and
briefly how their situation has been since then

Goal: this should be a clear statement that is a) specific (able to be clearly viewed as met
or not met), b) client based (it is something the client perceives as an issue, not the nurse,
and c) something that is relatively simple and able to be dealt with in a short period of
time.
II. Nurse/Client Interaction in Three-Column Format::
Record the actual conversation in a three column format. One column is for the Student Nurse’s
verbal and non-verbal communication. One column is for the patient’s verbal and non-verbal
communication. The final column is for the analysis of the interaction. The analysis section should
be the largest of the sections, and should be completed AFTER the interaction is completed.
ANALYSIS Section:

The analysis section is the most important section of the paper. It is not expected that you
have a perfect conversation that meets all of the emotional/psychological aspects of the
client. What is important is that you understand what you could have done to make the
conversation more meaningful and what you are doing to either encourage or block
therapeutic communication, Analysis means to look critically at what occurred and use this
information to see what changes would make it better.

COMPONENTS TO INCLUDE IN THE ANALYSIS COLUMN:

The Introductory, Working and Ending Phases: should be clearly identified.

Identify attending/responding skills: this includes all of the things that you did to make the client
trust you (i.e. sitting at eye level, providing privacy, etc…), and all of the different types of
responding skills that you used to try to encourage the conversation (i.e. open ended questions,
silence, restatement, etc…)

Identify cues: what cues (verbal and non-verbal) did the client give that made you respond the
way you did, ask the questions that you did, or use the non-verbal communication that you did?

Identify rationale: What were you thinking or feeling that made you respond to the client the way
you did? What did you hope to accomplish by your responses to the client? Why did you make a
certain statement?

Identify blocks/alternative responses: Did you say or do something that created a block in the
flow of the conversation? If you could go back and change any of your responses, what would
you do differently? What would you say? Actual statements/ alternatives should be written.
Were there other variables within the environment (within or outside of your control) that limited
the therapeutic interaction in some way?
III. Self-Evaluation Section:
At the conclusion of the interaction, you will reflect on the therapeutic process. For each of the
sections in the self-evaluation, write a paragraph addressing each area. Critically and carefully look
at how helpful the conversation was to the client, and how therapeutic the conversation was. How
would you feel if you were the client? How did you feel as you went through the interaction and after
reviewing it after the fact?

Overall Impression: Write a paragraph that critically looks at how therapeutic the conversation
was, and how effectively you assisted the client in achieving his/her goal. Did you use a variety of
therapeutic techniques? Did you consciously try to think about the techniques you were using and
what you were trying to accomplish by use of the techniques?

Effectiveness of Interaction:

Strengths: What were some of your strengths in communication in this interaction? List a few
therapeutic techniques you used that worked well.

Identify areas needing further improvement: Critically evaluate your interaction and identify
things that you did that detracted from the conversation. Include nonverbal and verbal barriers to
the interaction with suggestions about what you feel you could to work on in the future to be of
more help to your clients.
Did you meet your stated goal with this interaction?
A BRIEF EXAMPLE: This is deliberately brief and lacks information that should be included. It is
merely an example of various aspects of a process recording.
M.P. is an 80 year-old who was admitted for bilateral knee replacements. She is to be discharged
from the hospital today. She is to be admitted for a short time to a nursing home for Physical and
Occupational Therapy. She is upset about going to the nursing home.
GOAL: To allow M.P. to express her feelings about going to a nursing home, and to assist her to
begin to work through some of the issues that may be causing negative feelings.
PATIENT
NURSE
ANALYSIS
Good morning, M. How are you
I had previously introduced
feeling?
myself. Open ended statement
Good morning (down cast eyes,
sad tone of voice)
Working phase; Reflecting. I
You sound sad (sits at eye level
noticed how sad she looked and
close to client)
that her voices also conveyed this
message to me. I was hoping that
she would tell me how she was
feeling, and I reflected on what I
was seeing.
Well, yes, I am. I am going to a
nursing home today. (watery
eyes, wringing hands;
emphasized nursing home)
You will be able to continue PT
so that you will be able to take
care of yourself at home.
Yes, I know, but I still don’t like
it. (looking sad, looks down)
I miss my home and I won’t see
my dog, Sadie. (eyes tearful)
What in particular makes you
unhappy about going there?
(leans in closer)
You miss Sadie? (touched her
arm, and left my hand there for a
few seconds)
Oh yes!
Most nursing homes do allow pet
visits. Could your family bring
Sadie for visits?
My son can do that. I really miss
Sadie. (face becomes more
animated)
Block. I should have encouraged
her to talk about her feelings. I
should have said, “This upsets
you.”
Focusing in to help her look at an
area of concern. Moving in
closer to demonstrate my desire
to be there.
Validating. I could identify with
this. I took the cue that this was
something important to her. I
noticed the picture of her dog in
her room and had commented on
it earlier in the day.
Providing information and
support. I knew her family had
been in to see her every day, and
she spoke highly of them.
Reinforcing support. I was
opening up some options for her
to see that she could be with her
dog sometimes.
The sun is warm. You could visit
with her outdoors too.
I am going to talk to my son
about this. I look forward to
seeing Sadie, and I won’t be there
that long. (hope in her voice)
Validating. Can see her
expression and nonverbals are
telling me this message.
Yes
You feel better about going?
Termination. I am letting her
know of my concern and
willingness to talk to her.
I’ll be leaving now, but I will be
back in an hour. We can talk
again then if you would like.
Overall Impression: I feel like I did a good job of allowing her to open up about how she feels about
going to the nursing home and I think that helping her see that Sadie could still come to visit relieved
some of her anxiety.
Effectiveness of interaction: The goal was met to an extent. We only talked about one of her
concerns about going to the nursing home. There were probably other issues that she has too.
Strengths: I feel that I conveyed caring by my physical presence and gestures of concern. Touch was
very effective in conveying caring and focusing seemed to help her see what specific issues she was
really sad about.
Areas of Further Improvement Needed: I could have seen if there were other thoughts and feelings
that she could identify about why she was depressed about going to the nursing home. I need to look
more holistically at the situation. I was nervous and so latched on to the first and only thing that was
making her uneasy about going to the nursing home. I need to not look for easy solutions, but look at
the big picture and help the client to identify those issues that are important to her/him.