NCM117 RLE: reasonable, and that their problems are understood and will be fully
CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF
BEHAVIOR, ACUTE AND CHRONIC
WEEK 3: Interview and Process Recording
THERAPEUTIC RELATIONSHIPS
- shows the patient that the nurse is committed to forging a
INTERVIEW AND PROCESS RECORDING
Effective nursing interview includes:
 ACTIVE LISTENING
Active listening involves fully comprehending what a patient is
communicating through both verbal and nonverbal cues to
encourage the patient to expand on his or her symptoms and the
circumstances surrounding them.
 ADAPTIVE QUESTIONING aka Guided Questioning
Helps you encourage a patient to fully communicate without
interrupting the flow of his or her narrative. Request additional
information, when necessary, by asking the patient to clarify their
statements. Start with general questions then moving to more
specific topics. This helps patients open up, thus offering multiple
choices for answers. Also helps patients clarify their answers. Uses
verbal and nonverbal techniques. (Also called echoing)
 NONVERBAL COMMUNICATION
Reading and understanding these nonverbal cues help nurses
understand patients more fully, and using nonverbal
communication of their own. Posture, eye contact, facial
expression, etc.
 EMPATHY, VALIDATION AND REASSURANCE
Demonstrates that you understand and care about what a patient is
experiencing and helps establish a trusting nurse-patient
relationship. Validate patients' feelings to help reassure them that
their emotions are natural and reasonable. Can be verbal and
nonverbal. Ex: “I understand,” and offering of tissues when crying.
Help reassure patient that their emotions are natural and
addressed.
 PARTNERING AND SUMMARIZATION
As you conduct your interview, summarizing what the patient has
said is also helpful, as it demonstrates that you've been listening
and can fill in holes in the patient's story. An essential element as it
continuing partnership to his/her wellness.
 TRANSITIONS AND EMPOWERMENT
Empower them with the idea that their participation in the process
and working closely with their medical team can make a positive
difference in their outcomes. One way to put patient’s fear at ease.
Process recording are the written reports of verbal interactions with
clients. They are verbatim (to the extent that is possible) accounts,
written by the nurse or student as a tool for improving interpretation
communication techniques. Written account of all that transpired
during and immediately following the nurse-patient interaction.
Purpose
 To critically analyze communication and its effect on behavior
of the individual.
 To gain the patients confidence and get this cooperation.
 To establish rapport with the patient.
 To study the patients psychological social and emotional
behavior.
 It helps to increase the ability to identify problems and develop
skills in solving them.
 It gives students an opportunity to gain the ease and function in
written expression that are important for professional
development.
Goals and Objectives
 Establish a therapeutic nurse patient relationship.
 To give necessary health education to the patient.
 To obtain the identification data of the patient.
  To assess the insight of the patient.

General Guidelines
 Process recording is one method by which we can record the
content of an interview.
 Record the conversation verbal time.
 Use a recording device and obtain patients permission for using it
this will in reviewing the session if needed.
 Each process recording should be concluded with a summary.

Pre-requisite of process recording:

 Getting consent of the patient for the possibility of cassette
recording.
 Confidentiality should be maintained.
 Physical setting, calm and quiet environment.

Steps of process recording

1. Preparation
2. Record nurse patient interaction
3. Written process recording may begin with taken during the
interview
4. Identification Data
5. Present Complaint

Outline for Process Recording

Conclusion
Conducting a process recording gives the opportunity to improve
the communication skill, self-awareness, assessments, learning
observation and role playing. A process to listen recording provides
with an additional opportunity to practice nursing values and ethics.