This document outlines the process of process recording in a psychiatric setting. It defines process recording as the written account of the verbatim recording of interactions between nurses and patients. The key features are that it documents interactions in detail either during or immediately after for therapeutic and educational purposes. The purposes listed are to improve quality of care, assist students in planning and evaluating interactions, and develop self-awareness. An outline is provided that includes introductory information, objectives, the recorded interaction, analysis, and summary. Guidelines are given for environment, consent, confidentiality, and formatting. The overall goal of process recording is for nurses to gain skills in therapeutic communication and addressing patient problems.

1. Ms. Meril Manuel
Lecturer
VINE

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Thank you