Concorde Career College
NURSING PROCESS RECORDING
Patient Goals/Nursing Actions to assist:
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Interaction
Verbal/Nonverbal Interaction
Technique/ Rationale
Analysis
1
Medications/dosage
Classification/use for this client
Adverse effects noted/to be watched for
2
Assessment
STRENGTHS
WEAKNESSES
Appearance
Affect/Mood/ Attitude
Behavior/ Activity
Communication
Thought Process
Thought Content
Perception
Insight
3
Defense Mechanisms
Support system
Occupation/ skills
Stressors/ Coping
Skills
4
PROCESS RECORDING GRADING SHEET
To be scored by clinical instructor
Objectives
1. Identify goals/ planned actions appropriate for client
Possible
points
0- 20
2. Describe verbal/ nonverbal interaction verbatim (Word For Word)
0-10
3. Identify techniques used- indicate if therapeutic/ non-therapeutic; describe your
purpose for using this technique
0-20
4. Evaluate interaction( How/ why you interacted; how/why you might have
interacted differently; what future techniques/ approaches you will use
0-20
5. Assess client’s strengths/ weaknesses for each assessment area
0-10
6. Develop psychosocial nursing care plans based on assessment data.
0-20
1
2
3
4
5
*100 points total
Student must have a minimum of 80 points for satisfactory grade.
5
6