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Ms. Meril Manuel
Lecturer
VINE
DEFINITION
Recording of the conversation during the
interaction or the interview between the
nurse and the patient in the...
FEATURES
It may be written during or immediately
followed the interaction
It is a therapeutic tool in which the nurse us...
PURPOSES
To improve the quality of nurse patient
interactions.
To assist the student nurse to plan, structure
and evalua...
PURPOSES
To develop awareness about own
habitual, verbal and nonverbal communication
pattern and the effects on others.
...
PRE-REQUISITE FOR PROCESS
RECORDING
Physical setting
- Calm and quiet environment
(Interview rooms or bed side, if separa...
PROCESS RECORDING OUTLINE
A. Introductory material
Description of patient ( name, age education
level, health problems & ...
B. Objectives
Should be formulated prior to meeting.
Should be specific and function as a guide for
interaction.
Short ...
C. Record of interaction between nurse and
patient
Nurses should be truthful in recording what s
said and did by self and...
D. Analysis of the interaction
Analysis of the interaction should be done by
interpreting the verbal and nonverbal behavi...
E. Summary
The recording process should end with a brief
summary to evaluate whether the initial
objectives for the inter...
FORMAT FOR PROCESS RECORDING
Verbal response
Non verbal
response
Therapeutic
communication
technique
Interference
nurse Pa...
Thank you
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  1. 1. Ms. Meril Manuel Lecturer VINE
  2. 2. DEFINITION Recording of the conversation during the interaction or the interview between the nurse and the patient in the psychiatric set up with the nurses interference. It is the written account of verbatim recording of all that transpire/emerged, during and immediately following the nurse patient interaction
  3. 3. FEATURES It may be written during or immediately followed the interaction It is a therapeutic tool in which the nurse uses her therapeutic communication techniques for solving the patients problem. It acts as an educational, teaching, therapeutic and diagnostic tool.
  4. 4. PURPOSES To improve the quality of nurse patient interactions. To assist the student nurse to plan, structure and evaluate the interaction in a conscious level To gain competency in interpreting and synthesizing raw data under supervision.
  5. 5. PURPOSES To develop awareness about own habitual, verbal and nonverbal communication pattern and the effects on others. To identify the thoughts and feelings in relation to self and others. To increase observational skills, ability to identify the problems and gain skills in solving them.
  6. 6. PRE-REQUISITE FOR PROCESS RECORDING Physical setting - Calm and quiet environment (Interview rooms or bed side, if separate room is not available). Obtaining consent for the patient for recording the information. Maintain confidentiality of information.
  7. 7. PROCESS RECORDING OUTLINE A. Introductory material Description of patient ( name, age education level, health problems & length of stay in hospital). Date, time, place and duration of interaction Recording of nurses own thoughts and feelings before the interaction Reason for choosing the patient for process recording
  8. 8. B. Objectives Should be formulated prior to meeting. Should be specific and function as a guide for interaction. Short term goals - to establish a therapeutic relationship with patients. Long term goals- to prepare the patient and family for follow up and rehabilitation.
  9. 9. C. Record of interaction between nurse and patient Nurses should be truthful in recording what s said and did by self and by the patient. Observe for the nonverbal response ( eye contact, restlessness, pacing, biting nails, changing position). Nurses own thoughts and feelings should be recorded separately after writing the interaction process Patient overall response towards the interaction to be recorded.
  10. 10. D. Analysis of the interaction Analysis of the interaction should be done by interpreting the verbal and nonverbal behavior and patients thoughts and feelings evident from the interaction. Communication techniques used by the nurse also to be recorded. Nurses thoughts and feelings at the end of the interaction and plans made for further interaction should be stated. Time required to record is 30 min( 20 min for active interactions, 10 min for conclusion and planning for next interview).
  11. 11. E. Summary The recording process should end with a brief summary to evaluate whether the initial objectives for the interaction were met. It the objectives were not met, provide a brief analysis of the reasons
  12. 12. FORMAT FOR PROCESS RECORDING Verbal response Non verbal response Therapeutic communication technique Interference nurse Patient Nurse Patient Name of patient: Mr. / Mrs./ Miss. ____ Place : Name of the hospital: DOA: Date & Time: Objectives : (1),(2),(3) …… Conclusion Summary
  13. 13. Thank you

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