Harrison

Please type & print on only one side of paper. Completed PR must be submitted to your clinical instructor with a cover sheet
and a blank grading sheet in a folder.
Process Recording Template
Follow the PR Directions Sheet Carefully
Date: 9/11/16 (date of interation)
Clients Dx: Schizophrenia
Age: 49 yrs old
LOS: 20 days
Dialogue

Non Verbal
Communication
Hello! Good
-smiling, eye
morning my
contact with
name is Jeff. Im patient, standing,
a student nurse
at Kapiolani
Community
-patient standing,
College and Ill
brief eye contact,
be working with looking at floor,
you this
chose to sit near
morning. Ill be glass door
on the unit
12:30. Lets have
a seat and talk.
Hi. Yes, yes.
Okay. Hi, my
name is [patients
name]

Technique
-Introductory
statement

Student
Feelings
-Excited

Student
T/N
Thoughts
Im glad the
T
patient wanted
to talk. Im also
glad I didnt say
can we talk?
or is it okay if
we talk?

Analysis
3. I thought it was a solid
introduction. I stated who I am,
and my purpose.

Harrison
Nice to meet
you. So, tell me
about how
youre doing
today.
Im doing okay.
Much better. Im
getting better.
Its good to
hear that youre
doing better.
What brought
you to the
hospital?
Oh yes, okay,
okay. Im here
because of the
voices. Yeah.
The voices?
Please tell me
about these
voices.
Yes, yes. These
voices. Theyre
telling me to do
things. I cant eat
because of them

-sitting down,
facing patient,
hands on lap, eye
contact

-Open-ended
question
-General lead

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands
-sitting down,
-Open ended
facing patient,
question
hands on lap, eye -General Lead
contact

-Excited
-eager

It was nice to
hear at the
beginning that
he was doing
better. I want to
know what
better meant.
Better
compared to
what?

-Curious

This patient
T
seems really
fidgety. I hope
Im not making
him
uncomfortable.

4. The patient maintained

minimal eye contact throughout
the conversation. I felt as if I was
making him uncomfortable.

-Interested
-curious

How do these
voices lead him
to not eat? I
must dig
deeper.

3. My facial expression of
curiosity might have hinted to the
patient that I was going to ask for
elaboration.

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands
-sitting down,
facing patient,
hands on lap, eye
contact, curious
facial expression
-sitting down,
minimal eye
contact, looking at
floor and wrists,

-Restatement
-clarification

3. Sitting down in a comfortable

setting, facing the patient while
speaking, and maintaining eye
contact showed the patient that I
am here to listen.

Harrison
fidgeting with
hands, nodding
head
What do you
-sitting down,
mean when you facing patient,
say you cant eat hands on lap, eye
because of the
contact, curious
voices? What
facial expression
are the voices
telling you?
-sitting down,
minimal eye
Okay, so these
contact, looking at
voices, they
floor and wrists,
wont let me eat. fidgeting with
Theyre evil.
hands, shaky
voice, hesitant
I see. Please, go
on. What are the -sitting down,
voices telling
facing patient,
you?
hands on lap, eye
contact
Yes, okay. You
see, Im here
-sitting down,
because my
minimal eye
brother was
contact, looking at
worried I wasnt
floor and wrists,
eating. These
fidgeting with
voices wont let
hands
me eat. The
voices are telling
me theyre going
to explode my
food.

-Clarification

-Concerned
-Curious

What made
these voices
evil? I hope
its nothing that
I cant handle

-Minimal
encourager
-open ended
question

-worried
-shocked

The word
T
explode
already sounds
very violent and
dangerous. I
hope nobodys
safety would be
at risk.

4. The patient responded in

hesitation and what I interpreted
as fear. This showed me that the
voices in his head are threatening
in nature.

3. I was very shocked to hear

about the possibility of danger. I
wanted to know more about it
while maintaining therapeutic
professionalism.

Harrison

What do you
mean by
exploding your
food? Are you or
anybody going
to get hurt if this
happens?
If I eat food,
everything will
splatter all over
the place and
make a big
mess.
That must be
pretty rough for
you. So the
reason you cant
eat is because
these voices are
threatening to
explode your
food. That led to
your brother
being
concerned. Is
that correct?
Yes, yes. The
voices. They
wont let me.

-sitting down,
facing patient,
hands on lap, eye
contact
-sitting down,
minimal eye
contact, looking at
floor and wrists,
showing with
hands the severity
of the mess would
be from
exploding food
-sitting down,
facing patient,
hands on lap, eye
contact
-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, nodding
head

-clarification

-nervous
-unsure
-somewhat
relieved

Okay, thats
what he meant
by exploding
food. Good to
know that a
mess of food
would be the
worst possible
outcome.

-Expression of
empathy
-Paraphrase
-Check out

-sympathetic

It must be
tough not being
able to eat. Im
glad he has
family that
cares about
him

4. He used his arms and hands to

mimic the severity of the mess
from exploding food. That
piece of information displayed
the acuity of his schizophrenia.

3. I wanted to clarify my
understanding of his mental
conditions.

Harrison
These voices,
are they making
you want to hurt
yourself or
anyone else?

-sitting down,
facing patient,
hands on lap, eye
contact, leaned in
closer

Close ended
question

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, shaking
head, soft voice
You seem to be -sitting down,
Reflection of
very stressed out facing patient,
feelings
about this
hands on lap, eye
situation with
contact
the voices in
your head
-sitting down,
looking at floor
(No verbal
and wrists,
response)
fidgeting with
hands, nodding
head

-concerned

Good. He has
no suicidal or
homicidal
ideation. That
would have
really escalated
my concern for
him and others
in the mileu.

5. Although it is an important
question to ask, I deemed it nontherapeutic because it was a
close-ended question. I could
have said:
What are these voices telling
you to do toward yourself or
others?

-sympathetic

I need to get
back to open
ended
questions.

4. The patient just nodded. I

knew I had to continue on with
an open-ended question to
keeping the conversation
flowing.

Oh, no, no no.

They dont do
that. Only about
my food. But
they make me
angry.

Harrison
What do you
do while youre
here to control
your anger

-sitting down,
facing patient,
hands on lap, eye
contact

I like to go
outside. I like to
garden. I make
things too. See,
like this. Mhmm.
(showing bead
bracelets around
his wrists)

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, pointing to
outdoor lanai,
holding out wrist
to show bracelets
-sitting down,
-expression of
facing patient,
empathy
hands on lap, eye
contact, smiling

Very nice! Yes,

its pretty nice
outside. I see
why you enjoy
going outside
there are some
nice plants out
there. Those are
very nice
bracelets too.
Mhmm yes.
Thanks

-sitting down,
minimal eye
contact, looking at
floor and wrists,
smiles, nodding
head

Open ended
question

-curious
-interested

The staff does T

a good job with
keeping the
patients busy by
allowing them
to socialize and
engage in group
activities.

2. I could have restated what he

said about the voices making him
angry.
You mentioned that the voices
make you angry. What kinds of
activities do you take part in to
focus your emotions away from
the voices?

-impressed

He seems to be T
able to control
his emotions by
focusing on
external
stimulants.
Thats a good
coping skill to
have.

3. Smiling and complimenting

him could have served as a form
of positive reinforcement toward
his effective coping skills.

Harrison
[Name of
patient], earlier
you mentioned
that you were
doing better.
How have you
been doing
better,
compared to
when you first
got here [to
Kekela].
Oh, yes. Yes, I
have been doing
much better.
They dont bother
me much
anymore. I can
eat more
When you say
they dont
bother you
much, are you
referring to the
voices in your
head?
Yes, yes. The
voices. Yeah.

-sitting down,
facing patient,
hands on lap, eye
contact

focusing

-curious

They, as in, the T

voices, patients,
staff?

4. The smile on his face showed

that he is proud of his progress.
That made me curious as to what
his goals are.

-Clarification
-Close ended
question

-assured

Im glad to
know that these
voices arent
bothering him
as much as
before.

2. Although this question was

meant for clarification I could
have rephrased it into an openended question.
They dont bother you much
anymore? Explain what you
mean by that.

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, smiles

-sitting down,
facing patient,
hands on lap, eye
contact, curious
expression
-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, nodding
head

Harrison
I see. Im glad
you are getting
better. So, what
are your goals
that you want to
accomplish
during your
hospitalization
that will work
toward your
discharge?
I want to gain
weight. Yeah,
because I wasnt
eating much. I
want to gain
weight.
Your goal is to
gain weight.
How have you
been doing with
that so far?
Im doing good.
Yeah, Im doing
much better. I
gain 3 pounds so
far. Mhmm.

-sitting down,
facing patient,
hands on lap, eye
contact, smiling

-Open ended
question
-General Lead

-interested
-optimistic

Its important
to set goals for
yourself during
hospitalization.
Knowing that
you need to do
is important
discharge
criteria.

4. He seemed enthusiastic about

his progress. It showed optimism
and hope. His goals is a topic to
elaborate on.

-restatement
-Open ended
question

-hopeful
-proud

Good for him.

He has a goal
and hes
actively
working to
meet it

4. I realize that his fidgeting and

minimal eye contact is his norm.
His smile showed me that my
presence was not an
inconvenience and instead it was
helpful and therapeutic.

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, a little
more enthusiasm
in his vocals

-sitting down,
facing patient,
hands on lap, eye
contact
-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands, smiling

Harrison
Thats great.
Thats good
progress, good
for you. What
has been
working for
you?
I eat more.
Mhmm, yeah.

-sitting down,
facing patient,
hands on lap, eye
contact, smiling

-Open ended
question

-hopeful

Yes. That is
the goal

3. I was happy that I got to a

point where he seemed more
comfortable.

-Open ended
question

-hopeful

The staff is
doing a great
job at
improving his
condition. He
also adheres to
his medication
schedule. That
will further his
progression.

2. Although it was an open-ended

question, I feel as if I could have
rephrased it to focus on what
type of benefits he gets from the
meds.
What benefits are you seeing
from your medication
regimen?

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands

How have you

been tolerating
your
medications?

-sitting down,
facing patient,
hands on lap, eye
contact

Good, good.
Yes, they really
help.

-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands

Harrison
Okay, [name of
patient], you
gave me a lot of
information and
I thank you for
your time. You
told me that
youre here
because of the
voices in your
head. They tell
you that if you
eat, they will
make a huge
mess out of your
food. Because of
that, you
havent been
eating much,
which led to
your current
hospitalization.
The staff and
meds have been
helping you a
lot. During your
stay hear the
voices have been
getting better.
You have been
eating more and
plan to gain
even more

-sitting down,
facing patient,
hands on lap, eye
contact, smiling
-sitting down,
minimal eye
contact, looking at
floor and wrists,
fidgeting with
hands

-summarizing
-check out

-optimistic
-hopeful

Did I miss
T
something that I
should
mention?

3. My interest in this
conversation made it easy to
recall the things he said.

Harrison
weight. Is that
all correct?
Mhmm, yes.
That is all right.

Right on.
Please continue
to monitor your
weight to track
the progress
toward your
goal. Also,
continue to
adhere to your
medication
schedule and
continue to take
part in group
activities. It
sounds like you
know what you
must due to
achieve
discharge
criteria.
Continue

-sitting down,
facing patient,
hands on lap, eye
contact, smiling
-sitting down,
minimal eye
contact, smiling,
ready to stand up

-offering self
-accomplished

-hopeful
-optimistic

That went
quite well. Im
glad he opened
up. This
therapeutic
communication
thing is getting
easier and
easier

3. I felt very accomplished and

more confident. Selfimprovement methods
recommended.

Harrison
making
progress. It was
nice meeting
you, [name of
patient]. I will
be around until
12:30. Let me
know if you
need me. Again,
my name is Jeff.
It was nice
speaking with
you and thank
you for your
time.
Okay. Thank
you, thank you.
Yes, nice meeting
you.