Process Recording Example

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PROCESS RECORDING STUDENT ___x DATE ______9/6/2011____ PATIENT INITIALS ______KE____ PROCESS RECORDING # __1___ AGE ____21_ SEX _____Male_____ NURSE-PATIENT RELATIONSHIP PHASE __orientation________ SETTING: Unit 2 E . H C Psc Center. Patient is in general activity room area at 1500pm. Patient is pacing back and forth with a limp to his left leg. Several patients are in general activity room. GOALS: During this orientation visit, as a student nurse Iwill be able to: 1. Establish initial contact with KE 2. Assess patient's understanding on why he is here. | |EVALUATION/ANALYSIS PATIENT | |EVALUATION/ANALYSIS NURSE’S | | |PATIENT COMMUNICATION |COMMUNICATION |NURSE’S COMMUNICATION |COMMUNICATION |RESTATEMENT/CORRECTIVE RESPONSE | | |1.) |1.) |1.) |1.) | |1.) |Patientcould possibly have stubbed|Good Afternoon, my name is Arali |This was an acceptable form of |Reinstatement: Good Afternoon, my name is | |Patient is wearing flip flop sandals |his toe. |and I will be your student nurse |introduction. |Arali, and I am a student at SJC , can I talk | |and limping on left leg. | |today. |Thiswas a technique to undo the |with youfor a few minutes? | | |2.) At this point, realization | |possible

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