Process recording

Verna Bernal
Ivan Cabibi
Vanessa Cala
Erl Padilla
Joymae Rufin
Lovely Roche
Sheren Villarta
Aeron Quilisadio
Ashley Quijada
Objectives
After 1 hour of classroom discussion and demonstrations, the level III
students will be able to:
1. define the following terms:
1.1 process recording
1.2 communication
1.3 verbal communication
1.4 non-verbal communication
1.5 proxemics
1.6 active observation
2. explain the importance of process recording
3. review the concepts related to process recording
3.1. Mental Status Examination
 3.2. Therapeutic communication
3.3 Non-therapeutic communication
3.4 Ego Defense Mechanisms
4.enumerate the guidelines in recording observations
5. discuss the nursing responsibilities before, during, and after the process
recording
 DEFINITION OF TERMS
Process Recording

Written record of an encounter with a

patient that is as nearly verbatim as
possible, including both verbal and
nonverbal behaviors that the nurse and
the client.
a tool used by the student, the field
instructor, and the faculty advisor to
examine the dynamics of a particular
interaction in time
 DEFINITION OF TERMS
Communication

is the sending and receiving of information

and can be one-on-one or between groups
of people
a process by which information is
exchanged between individuals through a
common system of symbols, signs, or
behavior
 DEFINITION OF TERMS
Verbal Communication

Use of words to share information with

other people. It can therefore include both
spoken and written communication.
Effective verbal communication skills
include more than just talking. Verbal
communication encompasses both how
you deliver messages and how you receive
them
 DEFINITION OF TERMS
Non-verbal Communication

Communication that does not involve

words, such as body language, tone of
voice, and facial expressions
Nonverbal communication types include
facial expressions, gestures, paralinguistics
such as loudness or tone of voice, body
language, proxemics or personal space,
eye gaze, haptics (touch), appearance, and
artifacts
 DEFINITION OF TERMS
Proxemics

The study of distance zones between

people during communication
the branch of knowledge that deals with
the amount of space that people feel it
necessary to set between themselves and
others.
 DEFINITION OF TERMS
Active Observation

Watching the speaker’s nonverbal actions

as he or she communicates.
Observation is the active acquisition of
information from a primary source
Importance of Process
Recording
Helps an individual conceptualize and organize ongoing activities with client
systems, to clarify the purpose of the interview or intervention, to identify
strengths and weaknesses, and to improve self-awareness.

To critically analyze communication and its effect on behavior of the

individual.

To gain the patient’s confidence, get his/her cooperation, and to establish

rapport with the patient.
Concepts related
to Process
Recording
Mental Status Examination
I. GENERAL APPEARANCE
How the client looks such as their build, posture, level of alertness, attitude
towards examiner(cooperative or uncooperative), degree of cleanliness and
attire, hygiene and facial expressions
Common terms used to describe appearance are healthy, sickly, ill at ease,
looks older/younger than stated age, disheveled, childlike, and bizarre.
Unusually meticulous grooming and finicky mannerism may be seen in
obsessive-compulsive disorder
Poor hygiene and inappropriate dress may be seen with organic brain
syndrome
 A dirty, unshaven appearance with foul body odor may reflect depression, drug
abuse, or low socioeconomic level.
Reduced eye contact is seen in depression or apathy. Extreme facial
expressions of happiness, anger or fright may be seen in anxious clients.
Clients with Parkinson disease may have a mask-like, expressionless face.

Example Description
The client wore a white colored t-shirt with black shorts. He also wore jewelry such
as a necklace and a bracelet. His gate is brisk and the client has a slouched posture.
The client is 5’8’’ tall and his weight is 60 kg. He maintained an appropriate level of
eye contact. The clients’ hair is wavy, the texture is thick and the hair color is black.
The client has no evidence of scars or tattoos in his body. The client is well-
groomed, well-developed, well-built and is appropriate for his stated age.
II. BEHAVIOR/ MOVEMENTS
The client’s eye contact(poor, good, piercing) towards the examiner,
psychomotor activity (ex: agitation) and movements(tremors, abnormal
movements)
Bizarre behavior may be seen in the angry, mentally ill or violent client
Incongruent behavior may be seen in clients who are in denial of problems or
illnesses

Example Description
The client was calm and actively participative throughout the examination. He also
maintained good eye contact. Facial expressions were also present, like he is
expressive, relaxed, and alert. He doesn’t have any mannerisms while talking and
the client uses normal gestures during the interview. Overall, the client was still able
to follow commands or requests
 III. COMMUNICATION
1. Volume
How loud or soft the client is speaking
If the client is mute
Loud volumes may suggest mania meanwhile quiet may suggest depression

2. Productivity Rate
If the client is speaking normally, very slowly, rapidly
Pressure of speech

3. Goal Direction
Goal directed, spontaneous, hesitant, stuttering, speaks only when asked,
muttering
4. Tone
Having normal fluctuations or monotonous
Weak or strong tone

Example Description
Throughout the examination, the client was calm and actively participative. The
client is expressive about his thoughts during the interview. The client’s tone is
appropriate. The client’s voice is clear and understandable with good articulation of
words. The rate of my clients’ voice is expansive and talkative.
IV. THOUGHT FORMS
Thought Process

Describes the rate of thoughts, how they flow and are connected. - Normal:
tight, logical and linear, coherent and goal directed
Abnormal: associations are not clear, organized or coherent.
Note whether the patient responds directly to the questions. Document
whether the patient deviates from the subject at hand and has to be guided
back to the topic more than once.
1. Form - Process or form of thought can be logical and coherent or completely
illogical and even incomprehensible.
2. Disorders of Perception
- Illusions
- Hallucinations
- Delusions
- Phobias
 Thought Content
Content refers to what a person is actually thinking about: ideas, beliefs, preoccupations, obsessions
Aspects of thought content are as follows: obsession and compulsions, phobias, suicidal ideation or intent, homicidal ideation or intent, hallucinations, and
delusions.

Example Description
The clients’ thought process is linear, because as the client was given a question
about his opinions about the importance of safety protocols in COVID - 19, he was
straightforward in expressing his thoughts that was based on what he have learned
about the news about the things we must do in order to stay careful and healthy. In
his thought content, the client didn’t experience any signs of delusions and has no
suicidal and homicidal ideation.
V. EMOTION
Mood
refers to the more sustained emotional makeup of the patient's personality
The emotional state the patient tells you they feel (ex: Fantastic, elated,
depressed, anxious, sad, angry, irritable, good)
Often varies from sadness to joy to anger, depending on the situation and
circumstance
How the clients is feeling at the moment
Cooperative or friendly, expresses feelings appropriate to the situation
Anxiety, fear, irritability, depression and/rage are examples of altered mood
expressions
Eccentric moods not appropriate to the situation are seen in schizophrenia
Affect
Client’s immediate expression of emotion
The emotional state we observe
1. Range
→
a. Full (normal) wide range of emotional expression during the assessment;
variation in facial expression, tone of voice, use of hands, and body
movements.
→
b. Constricted or Restricted normal amplitude but restricted range
c. Blunted→ reduced emotional expression
→
d. Flat virtually no signs of affective expression should be present; the
patient's voice should be monotonous and the face should be immobile.
Note the patient's difficulty in initiating, sustaining, or terminating an
emotional response.
e. Labile→ unpredictable shifts in emotional state
2. Types
→
a. Euthymic normal mood
→
b. Dysphoric depressed, irritable, angry
→
c. Euphoric elevated, elated
3. Intensity
→
a. Blunted affect associated with schizophrenia, depression or post-
traumatic stress disorder
→
b. Heightened might suggest mania
→
c. Overly dramatic or exaggerated suggest personality disorders
4. Appropriateness
If it matches the mood (mood congruent vs. mood incongruent) - Appropriate
or inappropriate to the current situation
Delusional patients who are describing a delusion of persecution should be
angry or frightened about the experiences they believe are happening to them.
 Inappropriate affect for a quality of response found in some schizophrenia
patients, in which the patient's affect is incongruent with what the patient is
saying(e.g., flattened affect when speaking about murderous impulses). .

Example Description
The client’s mood is good, and from 1- 10 the client's current rate about his mood is
8. The client is quite nervous during the interview and because of his lack of ideas
about some words that are new to him which required guidance with follow up
information in order to help him from his confusion. The client’s objective emotional
state is euthymic. His affect is a full range, appropriate, with spontaneous emotional
reactivity. The client also has the appropriateness to content and congruence with
her stated mood.
VI. SENSORIUM & INTELLECTUAL
PROCESSES
1. Orientation
2. Memory
3. Ability to concentrate
Immediate, short term, long term
Both recent and remote memory are assessed. If the person has an organic
brain dysfunction, memory for remote past events commonly remains intact,
with loss of memory for more recent events. Any changes in memory or ability
to recognize familiar surroundings or people should be cause for further
investigation because it can be an early sign of a neurological problem that may
respond to medical treatment.
Example Description
1. Orientation
The client is fully aware and well-oriented about the date, day, month, year,
place of where he is right now, and the current president.

2. Memory
The client was given 3 unfamiliar words and was tasked to recall those words
after about 5 minutes .Then the client can immediately recall the 3 unfamiliar
words “anorexia, bulimia, kleptomania” after 5 minutes .

Short Term: The client can easily recall the things that happened earlier.
Long Term: The client can recall distant events that happened in his life.

3. Ability to concentrate
The client was able to focus during the interview.
The client's overall intelligence and cognition appear to be average.
VII. LEVEL OF CONSCIOUSNESS
Levels of consciousness are determined by the interviewer and are rated as (1)
coma, characterized by unresponsiveness; (2) stuporous, characterized by
response to pain; (3) lethargic, characterized by drowsiness; and (4) alert,
characterized by full awareness.
If patients exhibit decreased levels of consciousness note the stimulus required
to arouse the patient.

Example Description
Throughout the examination, the client was alert and actively participative,
answering all questions and doing what was asked.
VIII. ABSTRACT THINKING & INTELLECTUAL ABILITIES
1. Cognitive Skills
2. Intellectual Functions
Cognition
Attention, and concentration: the ability to focus, sustain and appropriately shift
mental attention
Alertness, orientation, memory and abstract reasoning
Usually not extensively reported and can be inferred from the interview or
reported as ‘intact’

Intellectual Functions
Information, Grammar, Vocabulary and Proverbs
Possible descriptors for vocabulary: grade school level, high school level, fluent,
consistent with education.
Altered attention span, impaired concentration, impaired calculation ability
Example Description
1. Cognitive Skills
∙ The client was able to explain the proverb that says “Actions speak louder than the
word” in an abstract response he said that “what you do is more important and
shows your intentions and feelings more clearly than what you say.”

2. Intellectual Functions
∙ The client was able to answer the questions that were being asked like “what is the
square root of 81” the client answered “9”. The client also answered the question
“How many planets are there in the solar system” the client answered “8” lastly the
client answered the question “Who is the father of our Wikang Pambansa?” the
client answered “Manuel L. Quezon”.
IX. SENSORY PERCEPTUAL PROCESSES

Example Description
The client didn’t feel any auditory and visual hallucinations. Thought and perceptual
acuity were within normal limits.
X. JUDGMENT
the ability to anticipate the consequences of one’s behavior and make decisions
to safeguard your well being and that of others
it is documented as either good, fair or poor.

Example Description
The client was asked to answer the question “What would you do if you saw your
close friend stole something from your other close friend, would you keep it as a
secret?” The client answered “no” and he has fairly handled the given situation in
which he is straightforward in choosing his decisions knowing that he is already
aware about the consequences of his actions.
XI. INSIGHT
awareness of one’s own illness and/or situation.
assess the patients' understanding of their condition.
To assess patients' insight to their illness, the interviewer may ask patients if
they need help or if they believe their feelings or conditions are normal.
It is documented as either good, fair or poor.

Example Description
Overall, the client has a good and logical insight, where he has a clear
understanding about why he is currently examined for his mental status, and
according to the client because of this interview he learned new things about him
that made him know and aware about it.
OVERALL ASSESSMENT
(based on above mentioned parameters)
The client has good hygiene and grooming. The client was calm and actively participative
throughout the examination. He also maintained good eye contact. The client speech
was expansive, appropriate with soft volume. The client communicates clearly and can
properly construct his thoughts or answer without any difficulty. The client did not show
any signs of delusions and has no suicidal ideation and homicidal ideation. The client has
the appropriateness to content and congruence with his stated mood. The client's
overall intelligence and cognition appear to be average. Throughout the examination, the
client was alert and actively participative, answering all questions and doing what was
asked. His abstract and intellectual abilities are average. The client didn’t feel any
auditory and visual hallucinations. Thought and perceptual acuity were within normal
limits. He has fairly good judgment and he is straightforward in choosing his decisions
knowing that he is already aware about the consequences of his actions. The client has a
good and logical insight.
 Therapeutic
Communication
An interpersonal interaction between the nurse and the client whereby the
nurse aims to understand the client’s specific needs to improve the efficacy
of information exchange.

Proxemics
- The study of distance zones between people when communicating
Intimate Zone (0-18 inches between people): For
people that desire physical contact between
each other such as parents with young children,
couples, etc. Violating this space will result in
anxiety
Personal Zone (18-36 inches): For families and
friends who are communicating with each other
Social Zone (4-12 ft): For communication in
social, work, and business settings.
Public Zone (12-25 ft): Acceptable when
communicating between speaker and audience,
small groups, and informal settings.
Touch
- As intimacy increases, the comfortable distance decreases between people

1. Functional-professional touch: used in
examinations or procedures like when a
nurse touches a patient for physical
exams
2. Social-polite touch: used when greeting
each other
3. Friendship-warmth touch: Longer
physical displays of friendship such as
hugging or throwing an arm around the
shoulder of a good friend
4. Love-intimacy touch: tight hugs and
kisses between people that love each
other such as good friends, lovers, and
family
Active Listening
- Limiting mental activities while listening to a client, allowing complete
concentration on what the client is saying

Active Observation
- Giving focus towards the nonverbal aspect of the speaker’s
communication
Therapeutic Techniques

Technique Description Example

The nurse indicates that they

“Yes”, “I get
Accepting have heard and understood

you”, nodding
what the client has said

Making sure that your “When you say

understanding is in line with that, do you
Broad openings
what the client is actually trying mean…?”, “Do you
to say use that word as”

 “When you say

Making sure that your
that, do you
Consensual understanding is in line with what
mean…?”, “Do you
validation the client is actually trying to say
use that word as”

“How does your

Encouraging Seeing things from the client’s situation make
description of

perspective by allowing them to you feel”, “does

perceptions describe their perception that make you feel
anything”
“When this
Encouraging Allowing the client to attribute happened what
expression feelings with experiences were your

feelings?”

 “How will you

handle this
Asking the client to consider differently next
Formulating
actions that will be needed in time”, “What are
plan of
future situations ways for you to
action

manage this
feeling in the

future”

“let’s go back to
Concentrating on a single point
your point about”,
to prevent overwhelming the
Focusing “which experience
client with too many factors or
troubled you the
problems
most”
 “I notice that you
Making Verbalizing your perception to help are grabbing your
observations the client understand something stomach”, “Are you
uncomfortable
when…”

“How will you
handle this
Asking the client to consider actions differently next
Exploring that will be needed in future time”, “What are
situations ways for you to

manage this
feeling in the
future”
 “I’m here to…”,
Presenting the available facts to “Your
Giving
increase knowledge about a topic appointment
information

schedule is…”

“There is no one
Stating what is real that the client behind you”, “That
Presenting

has misinterpreted sound was from

reality

outside”

Time period with no verbal

Silence interaction that allows clients to
put their thoughts into words.
 “I’m here to…”,
directing client action, thoughts, “Your
Reflecting
and feelings back to the client. appointment
schedule is…”

Client: “I’m really

Rephrasing or repeating what the sad and
client has
said.
Restating
heartbroken.”
Nurse: “You’re
really sad and
heartbroken.”

Organizing what has already “You said that…”,

Summarizing been said previously to focus on “Today we talked
the relevant details about…”
 Non-Therapeutic
Communication
Communication between the nurse and
the client whereby the communication
techniques of the nurse hinder or
damage professional relationships. This
leads to the client feeling discouraged to
further express their ideas and feelings,
as well as engender negative responses
from others.
 Non-therapeutic Communication Techniques

Technique Rationale Example

Telling the client what to

do. This implies that only “I think you should do this”
Advising
the nurse knows what is “Why don’t you do that.”
the best course of action.

Invalidating the client’s

“Everybody goes through
Belittling feelings feelings by comparing them
that”, “I felt that at your age
expressed to how other people feel or
too”
the nurse themselves
 Showing that you agree with
the client. This gives the
impression that the client is
right because the nurse is in
Agreeing ““That’s right.”
agreement with them and
“I agree.”
there is no opportunity for

changing their minds

because the nurse agrees
with them.

Demanding proof from the “If there’s a girl next to me

client causes the client to then why can’t I see her”,
Challenging
defend their “If you’re dead, why is your
misinterpretations heart beating”
 Protecting an entity from
a client’s verbal attack “The hospital is very
Defending implies that they have no reputable”, “The
right to express doctor is a fine man”
impressions, opinions, or
feelings

Opposing the client’s ideas

implies that the client is
“That’s not correct”, “I don’t
Disagreeing wrong which will make the
agree with that”
client defensive about said
ideas
 Denouncing the client’s
actions, behavior, or ideas.
This makes it show that the
“That’s bad”, “I’d rather
Disapproving nurse has the right to judge
you wouldn't”
the client’s thoughts and
actions and that the client
is expected to please the
nurse
Responding to a figurative Client:
comment as if it was fact “They’re looking in my head
Giving literal rather than exploring the with a television camera.”
responses client’s feelings in Nurse:

expressing those “Try not to watch television.”
comments OR “What channel?”

 Saying what the

client thinks or feels if “good”
implies that the opposite is
“bad.”
Approval, then, tends to limit
“That’s bad”, “I’d rather
Giving approval the client’s freedom to think,
you wouldn't”
speak, or act in a certain
way.
This can lead to the client’s
acting in a particular way
just to please the nurse.

 Attributing the source of

thoughts, feelings, and “What makes you say
Indicating the behaviors to others. This that”, “Who told you
existence of an implies that the client was that you were a
external source made to feel that way by prophet?”
something else.

Telling the client the

meaning of their “What you really mean is .
experience. This takes away . .”
Interpreting
the meaning for the client “Unconsciously you’re

because their thoughts and saying . . .“

feelings are their own and

no one else’s
 Changing the subject, Client:
which takes away the “I’d like to die.”
Introducing an initiative to control the Nurse:
unrelated topic conversation away from the “Did you have visitors
client. last evening?

“Now tell me
about this
Persistent questioning, problem. You
know I have
which makes the client feel to

Probing used or invaded find out.”

“Tell me your psychiatric
history.”

 Asking the client to provide

an explanation for their
thoughts, feelings, or “Why do you think
Requesting an
behaviors. This can often that”
explanation
intimidate the client which
makes them defensive

Asking questions meant to

Asking questions meant to check the client’s degree of
Testing check the client’s degree of insight, forcing them to
insight, forcing them to recognize their problem
recognize their problem “What hospital is this?”, “Do
you still have the idea
that…”

 Offering meaningless
cliches, which have no "Keep your chin up", "You
Making Stereotyped
value in hte nurse-client got this", "Just smile"
Comments
relationship

Ego Defense Mechanisms

Unconscious resources
used by the ego to reduce
conflict between the id and
superego, are a reflection
of how an individual deals
with conflict and stress.
Mechanism Definition Example

Napoleon complex:
diminutive man becoming
Overachievement in
emperor
one area to offset real

Compensation or perceived
Nurse with low self esteem
deficiencies in another
working double-shifts so
area
that her supervisor will like
her
 Expression of an
Teenager forbidden to see
emotional conflict
X-rated movies is tempted
through the
to do so by friends and
Conversion development if a
develops blindness, and the
physical symptom,
teenageris unconcerned
usually sensorimotor in
about the loos of sight
nature

Failure to acknowledge
an unbearable Spending money freely
condition; failure to when broke.
Denial admit the reality of a

situation or how one Waiting 3 days to seek for

enables the problem to severe abdominal pain.
continue.
 Amnesia that prevents
Dealing with emotional
recall of yesterday’s auto
conflict by a temporary
accident.
Dissociation alteration in

consciousness or
Adult remembers nothing
identity.
of childhood sexual abuse

Immobilization of a
Never learning to delay
portion of the
gratification
personality resulting
Fixation

from unsuccessful
Lack of clear sense of
completion of tasks in a
identity as an adult
development stage.
 Modeling actions and
opinions of influential
Nursing student becomes a
others while searching
critical care nurse because
Identification for identity, or aspiring
this is the specialty of an
to reach a personal,
instructor she admires.
social, or occupational
goal.

Separation of the
emotions of a painful
event or situation from Person shows no emotional
Intellectualization the facts involved; expression when discussing
acknowledging the a serious car accident.
facts but not the
emotions.
 Accepting another
Person who dislikes guns
person’s attitudes,
Introjection becomes an avid hunter,
beliefs, and values as
just like his best friend.
one’s own.

Unconscious blaming Man who has thought

of unacceptable about same-gender sexualo
Projection
inclinations or thoughts relationship had never had
on an external object. one beats a man who is gay.

Excusing own behavior

to avoid guilt, Man says he beats his wife
Rationalization responsibility, conflict, because she does not listen
anxiety, or loss of self- to him.
respect.
 Acting the opposite of Woman who never wanted
Reaction formation what one thinks or to have children becomes a
feels. supermom.

Moving back to a
previous A 5-year old asks for a
Regression developmental stage to bottle when new baby
feel safe or have needs brother is being fed.
met.

Excluding emotionally
painful or anxiety- Woman who has no
Repression provoking thoughts memory of the mugging she
and feelings from suffered yesterday.
conscious awareness.
 Overt or covert
antagonism towards Nurse is too busy with tasks
Resistance remembering or to spend time talking to a
processing anxiety- dying patient.
producing information.

Substituting a socially Person who has quit

acceptable activity for smoking sucks on hard
Sublimation
an impulse that is candy when the urge to
unacceptable. smoke arises.

Replacing the desired

Woman who would like to
gratification with the
Substitution have her own children
one that is readily
opens a day care center.
available.
 Ventilation of intense
feeling toward persons Child who is harassed by a
Displacement less threatening than bully at school mistreats a
the one who aroused younger sibling.
those feelings

Conscious exclusion of
A Student decides not to
unacceptable thoughts
Suppression think about a parent’s
and feelings from
illness to study for a test.
conscious awareness.

Exhibiting acceptable
Person who cheats on a
behavior to make up
undoing spouse brings the spouse a
for or negate
bouquet of roses.
unacceptable behavior.
 Guidelines in Recording
Observations
Make sure to have a calm and quiet environment. Use interview rooms or bedside if a
separate room is not available.
Before the meeting with the client, develop a short-term goal that is client centered
and that will serve as a guideline and purpose for the communication/session.
Obtain content from the patient for recording the information.
Always maintain confidentiality of information
Describe the setting and your plans to therapeutically approach the client at the
beginning of the session with sufficient clarity and detail so that the instructor will be
helped in his/her understanding of the situation.
Always be truthful in recording what is said and one by self and patient.

Observe non verbal responses during the interview eye contact, restlessness, pacing,
biting nails, changing positions).
Communication techniques used by the nurse should also be recorded.
Take note of the time required to record - 30 min. For active interaction and 10 min. for
conclusion and planning for the next interview).
Always end the recording process with a brief summary to evaluate whether the initial
objectives for the interaction were met. If objectives are not met, provide a brief analysis
of the reasons.
Nursing responsibilities Before, During, and After the
Process Recording
Before
Inform the client that you will be recording and noting down the conversation and get
his/her consent. Assure the client of confidentiality.
Prepare the physical setting where the session will be held. The setting should be

calm and quiet and make the client feel comfortable. The setting should also be
private in order to uphold privacy.
Prepare the materials that will be used during the session. This includes the recording
sheets where the verbatim account and analyses will be written and the audio or
video recording device.
Prepare yourself metnally and emotionally in order to avoid having assumptions or
biases against the clent or imposing our own feelings onto the client.
During
Appropriately use the various techniques of therapeutic communication in dealing with
the client.
Listen attentively and observe the client. Note both verbal and non-verbal cues
manifested by the client and acknowledge the client’s statements.
Position the recording equipment where the client will not be distracted.
Collaborate with an objective witness in order to analyze the client more accurately

After
Reassure the client that what transpired during the session will be confidential.
Do after care. Put the materials back in their proper places.
Accomplish proper documentation and evaluation.
The nurse or the student nurse should reflect on the session: whether therapeutic
communication was applied well and how to improve on process recording.