PROCESS RECORDING

Please type & print on only one side of paper. Completed PR must be submitted to your clinical instructor with a cover sheet
and a blank grading sheet in a folder.
Process Recording Template
Follow the PR Directions Sheet Carefully
Date: 9/16/16
Clients Dx: Autism Spectrum Disorder
Age: 15
LOS: 5 days
Dialogue
1. Writer:
So, tell me
why youre
here at Kahi.
Patient: I was
really angry
and I tried to
kill myself

*few
exchanges
later
2. Writer:

Non Verbal
Communicatio
n
Sitting upright
and at eye-toeye level.
Facing patient.
Maintaining
eye contact.

Technique
General
lead

Student
Feelings

Student
Thoughts

T/
N

Motivated

Here we go.

Sitting upright
with feet on
floor; hands
relaxed in lap.
Facing writer.
No fidgeting.

3. My non-verbal communication during this

exchange was intended to show a respect for
the client, and to let him know that I was
genuinely interested in what he had to say. It
contributed positively to the nurse-patient
relationship as it helped to develop rapport.
1. The dialogue in this exchange focuses on
the clients hospitalization.

Openended
question
Maintains eye

Analysis

confident

Okay, my
first priority
is now to
perform a

1. The dialogue in the exchange

demonstrates a focus on mental status
examination.

PROCESS RECORDING

Tell me when contact.

you had
Sitting upright
these suicidal
thoughts last. Patient:
Maintains eye
Patient:
contact. Appears
Sunday. The
comfortable.
day that I
came here.

3.Writer:
So since
Sunday, you
havent had
any thoughts
of hurting
yourself?

Maintains eye
contact.

safety
assessment.

check out
(a closedquestion)

relieved.

Alright, hes
is not
currently a
risk to
himself or
others.

Close-ended questions are communication

errors. However, I did need to assess patients
safety; and I had already used an open-ended
question in the previous exchange asking the
same thing. I used the check-out here to
confirm that I am hearing him correctly and
thus, I would not rephrase this exchange.

restatemen
t

curious

What does
he mean
better,
now.

3. Maybe by leaning forward (non-verbal

communication), I caused him a little anxiety
and thats why he broke eye contact and picked
at his hands? Again, I meant to show an
interest for what the client was going to say. I

Patient:
Maintains eye
contact. Appears
comfortable.

Patient: No. I
feel better
now.

4. Writer:
You feel
better, now?
Patient: Yeah.

My back comes
off the seat as I
lean forward.
Maintain eye
contact. Hands

PROCESS RECORDING
I was really
angry but
after I got
here Im okay
now.
*skips an
exchange
5. Writer:
Well if you
do get angry
again and
you feel like
killing
yourself, tell
me what you
would do?
Patient: Go
tell my peers.
Or [nurses
name]
*skips an
exchange
6.Writer:
You
mentioned
being
stressed out
with school
and stuff.
Help me to
understand

fold together.
Patient: Breaks
eye contact to
pick at hands
briefly.
Writer:
open ended progressive
Maintains eye
question
contact.
Remained
leaning forward
a little bit.

dont think that it contributed to the interaction

in a negative way, unless I really did cause him
some anxiety. Because one goal of the milieu is
to reduce stressors and anxiety.
Lets get to
the juicy
information.

4. The clients nonverbal communication spoke

to me. It was a little peculiar that he
maintained steady eye contact as he responded.
But I took it that what he said, he genuinely
meant; and I believed at that time he would
have been able to notify someone if he was
feeling suicidal.

4. Because the patient kind of fidgeted when I

leaned forward, I figured it would be an
appropriate time to sit back and provide a little
more distance between us so that client did not
feel cramped and inhibited from expressing
himself.

Patient: resumes
eye contact.
Appears to be
comfortable.

Maintains eye
contact. Rested
my back
against the
chair after
providing my
statement.

open
clarifying
question

Comfortable

Lets see
whats going
on with this
child.

PROCESS RECORDING

what you
meant by
that.
Patient:
Because I was
so busy. I
work three
jobs. My
uncle is the
CEO of
Hawaiian
airlines and
Im a flight
attendant for
them. I also
work for the
rail company
in Japan and
also, I make
cookies.
7. Writer:
Silence
Patient: Plus
Im four
months
pregnant now
and I already
have a child
at home.

Patient: breaks
steady eye
contact. Glances
around and
intermittently.
Then resumes
brief periods of
eye contact.

Writer: Silence
Maintains eye
contact as he
speaks, but then
looks back at
hands briefly.
Posture is not as
upright as it was
initially.
Shoulders a bit

Silence

Confused.

Im sensing
some
disturbance
in thoughts.
Delusions.
How am I
going to
respond to
this?

3. My non-verbal communication contributed

positively to our interaction. I wanted him to
continue speaking, because I felt unsure of
how to respond therapeutically to what he just
said; and I knew that, to change the subject
without acknowledging the feelings he had just
shared, would have been a communication
error. And thankfully, he continued to lead the
conversation which allowed me a chance to
form a therapeutic response.

PROCESS RECORDING
more droopy.
Maintains eye
contact.

8. Writer:
You look
overwhelmed
as youre
Patient: avoids
telling me
eye contact.
this.
Glances around
a little bit and
Patient:
head tilted
Silence.
downward, not
dramatically.
9. Writer:
Maintains eye
That sounds contact. Sitting
like a lot of
upright.
responsibilit
y for
Patient:
someone who Becomes more
is your age
animated.
and still
Postures upright
going to
while speaking.
school.
Patient: Yeah.
It is. And they
tease me
about it at
school.
10. Writer:
Tease you
about what?

Sitting upright.
Maintaining
eye contact.

Patient: Cause Patient:

Im different. same as above

Reflection
of feeling

Confident

Oh I know
what I can
say!

expression
of
empathy.

Confident

great
therapeutic
response.

1. The dialogue in this exchange

demonstrates focus on triggers.

openclarifying
question

sad

I think this
is going in
the right
direction.

1. The dialogue in this exchange

demonstrates focus on triggers.

PROCESS RECORDING
They laugh
when I tell
them Im
pregnant.
11. Writer:
Tell me how
you respond
to people
teasing you.

Maintaining
eye contact.
Back resting
against chair
sitting upright.

Patient: Well
before I
would get
really angry
and yell at
them.

Patient:
sitting upright.
Appears
comfortable.

*skips one
exchange
12. Writer:
So they tease
you because
youre
different,
and that
makes you
very angry?

Sitting upright.
Maintained eye
contact.

Patient: yeah.
13. Writer:
Tell me what
any of this
has to do

Openended
question

curious

remember,
connect the
dots.

paraphrase

progressive.

were
getting
there!

momentous

keep going!
Connecting
the dots
baby.

Patient: sits
comfortably.

Glance down at
my hands.
Catch myself
doing so, and

2. Self-improvement: This question is

appropriate. But maybe I could have responded
differently by asking the client to explain what
he meant by different.

1. The dialogue in this exchange

demonstrates focus on triggers.

PROCESS RECORDING
with you
being here,
right now.
Patient: I got
so angry.
Thats why I
choked
myself.
*few
exchanges
later
14. Writer:
So what if
you leave
here, go back
home, go
back to
school, what
if someone
teases you
againtell
me how you
might
respond
differently?
Patient: Use
different
coping
methods that I
learned here.
Tell my mom.

refocus sights
back to client.

Connecting
the dots!

Patient:
continues to sit
comfortably.

Sitting upright.
Maintained eye
contact.
Patient:
Continues to
make eye
contact as he
speaks.

Openended
question

surprised

Did he
really just
say copingmethods and
peers? He
must have
learned
these terms
while he was
here.

1. The dialogue in this exchange

demonstrates focus on discharge
planning.

PROCESS RECORDING
Tell my peers.
Tell my
teacher.
15. Writer:
Different
coping
methods
what do you
mean?
Patient: I
would get
away from
whoevers
teasing me
and tell my
teacher if Im
mad instead
of hurting
myself
16. Writer:
Uh-huh.
Patient: Or I
could talk to
my brothers
and sisters. I
could hug my
dog.
17. Writer:
What would
you do if you

Sitting upright.
Maintained eye
contact.

openclarifying
question

curious

I wonder
what he will
say?

minimal
encourager

neutral.

Hey, thats
T
something to
explore with
the patient:
psychosocial
relationship
s

Openended
question

accomplishe
d

Alright!

Patient:

Sitting upright.
Maintained eye
contact.
Patient: Starts
glancing over at
the other clients
on the unit as
they move
around.
Glancing over
to see what
client is

4. I noticed the patients concentration begin to

decline. I began to think, okay, we should wrap
up the conversation here and we can pick up
again later.

PROCESS RECORDING
get so angry
again and
you feel like
harming
yourself?
Patient: I
would tell my
peers. My
teacher. Or
my mom.
**Stop

directing his
attention to.
Patient: