NUR 2520C – Psychiatric Mental Health / Psychiatric Nursing

Process Recording

Name __________________________________

General Information:
Patient’s Initials: Age of Patient:
Patient’s Diagnoses:
Milieu / Setting / Descriptive Atmosphere:
Mental Status Examination:
General Appearance:
Level of Consciousness:
Dress:
Facial Expressions:
Posture:
Level of Understanding:
Gait:
Grooming:
Disheveled:
Dressed Inappropriate for Season:
Psychomotor Behavior:
Activity Level:
Eye Contact:
Attitude Toward the Nursing:
How the Client Arrived on Unit:
Mood:
Depressed / Sad:
Labile:
Elated:
Expansive:
Euphoric:
Anxious:
Affect:
Blunted:
Flat:
Restricted:
Depressed:
Excessively Bright:
Expansive:
Angry / Explosive:
Quality of Speech:
Clear / Slurred / Aphasic:
Rate: Normal / Slow or Latent / Fast:
Spontaneous:
Talkative:
Whispered:
Monotone:
Mumbles:
Loud:
Rapid / Pressured:
Stuttered:
Refuses / Non-Communicative:
Perceptual-Sensory Disturbances:
Hallucinations: Auditory / Visual / Tactile / Olfactory:

Illusions:

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Thought Content:
Compulsions:
Delusions: Insertions / Paranoid / Somatic / Jealousy:
Phobias:
Obsessions:
Anxiety Level:
Thought Processes:
Loose Associations:
Flight of Ideas:
Phobia’s:
Word Salad:
Confabulation:
Blocking:
Disorganization:
Higher Brain Function – Mini-Mental Examination:
Orientation: Person / Place / Time / Situation:

Memory: Remote / Recent / Recent Past / Immediate Memory / Immediate Recall:

Concentration & Attention:

Visio-Spatial Abilities:
Abstraction & Proverb:

Impulsivity:
Judgment:
Insight:
Reliability:
Psychosocial Assessment:
Recent Stressors:

Psychiatric Treatments or Counseling / Psychotherapy:

Quality of Support Systems & Strengths:

Presence & History of Suicidal Ideations, Gestures, & Risk Assessment:

Presence of Homicidal Ideations, Gestures & Risk Assessment:

Present & Past Coping Patterns / Skills:

Self-Concept, Self-Esteem, & Strengths:

Cultural Needs:

Legal History:

Spiritual Assessment:

Using Erickson’s 8 Stages of development: In what stage should the client be according to his/her
Age?

What Prior Developmental Stage, if any, seemed to be unsuccessfully resolved by this client?

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Nursing Diagnoses in R/T….AEB…form:
Outcomes for Client Exchange
2 – 3 outcomes (at least one short term
and one long term) for conversation must
be client-centered, convey openness of
exchange; They must be timed,
measurable, & realistic in the patients’
language & level of functioning.
Psychiatric Process Recording Care Plan
Nursing Interventions Evaluation of Outcomes
Nursing interventions are to be independent nurse-centered actions, which Was your outcome met? Why or why not?
assist the patient meet outcomes. They may include assessment, teaching & What needs continued evaluation?
collaboration with other disciplines. Which outcome/s needs to be followed by other
Minimum of 3 interventions. Psychiatric Services?
Time Interventions – q15, q30, q1hour, qd, qid, Teach on day of
admission, during conversation, day of d/c, reinforce PRN, etc.
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 Verbal Content (In Quotes) Non-Verbal Content (Body Language & Identify Therapeutic / Non-Therapeutic With Each Exchange; Evaluation the
Identify (P – Patient) (N – Nurse) Expressions of Client & Nurse) Techniques used. Identify Defense Effectiveness of Your Comments & Suggest
Mechanisms used by the client. Improvements If Needed

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 Verbal Content (In Quotes) Non-Verbal Content (Body Language & Identify Therapeutic / Non-Therapeutic With Each Exchange; Evaluation the
Identify (P – Patient) (N – Nurse) Expressions of Client & Nurse) Techniques used. Identify Defense Effectiveness of Your Comments & Suggest
Mechanisms used by the client. Improvements If Needed

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 Verbal Content (In Quotes) Non-Verbal Content (Body Language & Identify Therapeutic / Non-Therapeutic With Each Exchange; Evaluation the
Identify (P – Patient) (N – Nurse) Expressions of Client & Nurse) Techniques used. Identify Defense Effectiveness of Your Comments & Suggest
Mechanisms used by the client. Improvements If Needed

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 Verbal Content (In Quotes) Non-Verbal Content (Body Language & Identify Therapeutic / Non-Therapeutic With Each Exchange; Evaluation the
Identify (P – Patient) (N – Nurse) Expressions of Client & Nurse) Techniques used. Identify Defense Effectiveness of Your Comments & Suggest
Mechanisms used by the client. Improvements If Needed

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 Rubric for Psychiatric Daily Process Recording
Name: Rubric Grade:
Subject: Satisfactory – Meets Competency Unsatisfactory – Does Not Meet Competency
General Information General Information is clearly presented. Milieu / General Information is missing and/or Milieu / Setting &
Setting & Atmosphere are described accurate details. Atmosphere are not described using accurate details.
Clients General Clients General Appearance is complete and properly Clients General Appearance is missing and or inappropriately
Appearance recorded using appropriate descriptors within key recorded using inappropriate language with the key prompts.
prompts.
Grooming Clients Grooming is complete and properly recorded Clients Grooming is missing and or inappropriately recorded
using appropriate descriptors within key prompts. using inappropriate language with the key prompts.
Mood Clients Mood is complete and properly recorded using Clients Mood is missing and or inappropriately recorded using
appropriate descriptors within key prompts. inappropriate language with the key prompts.
Affect Clients Affect is complete and properly recorded using Clients Affect is missing and or inappropriately recorded using
appropriate descriptors within key prompts. inappropriate language with the key prompts.
Quality & Rate of Clients Quality & Rate of Speech is complete and Clients Quality & Rate of Speech is missing and or
Speech properly recorded using appropriate descriptors within inappropriately recorded using inappropriate language with the
key prompts. key prompts.
Perceptual-Sensory Clients Perceptual-Sensory Disturbances is complete Clients Perceptual-Sensory Disturbances is missing and or
Disturbances and properly recorded using appropriate descriptors inappropriately recorded using inappropriate language with the
within key prompts. key prompts.
Thought Content Clients Thought Content is complete and properly Clients Thought Content is missing and or inappropriately
recorded using appropriate descriptors within key recorded using inappropriate language with the key prompts.
prompts.
Thought Processes Clients Thought Processes is complete and properly Clients Grooming is missing and or inappropriately recorded
recorded using appropriate descriptors within key using inappropriate language with the key prompts.
prompts.
Higher Brain Function Clients Higher Brain Function is complete and Clients Higher Brain Function is missing and or inappropriately
properly recorded using appropriate descriptors within recorded using inappropriate language with the key prompts.
key prompts.
Psychosocial Clients Psychosocial Assessment is complete and Clients Psychosocial Assessment is missing and or
Assessment properly recorded using appropriate descriptors within inappropriately recorded using inappropriate language with the
key prompts. key prompts.
Spiritual Assessment Clients Spiritual Assessment is complete and properly Clients Spiritual Assessment is missing and or inappropriately
recorded using appropriate descriptors within key recorded using inappropriate language with the key prompts.
prompts.
Erickson’s 8 Stages of Developmental Level is correct according to his/her Developmental Level is missing and/or prior Developmental
Man Evaluation age. Prior Developmental Stage unsuccessfully Stage unsuccessfully resolved documentation is missing.
resolved is documented within framework of key
prompts.
Patient Centered Correctly develops an outcome that is written Outcome/s are missing and not written correctly, and not
Outcome/s correctly, are patient-centered, timed, measurable, patient-centered, timed, measurable, and unrealistic.
and realistic and outcomes are written correctly. Outcomes are not written correctly.
Nursing Interventions Selects 3 credible interventions to meet outcomes, Interventions are missing and/or not credible to meet
interventions are timed, independent, nurse-centered, outcomes, and interventions are not timed, and not
accurate, and patient specific. independent, and nurse-centered, and inaccurate, and not
patient specific.
Evaluation of Evaluation states the results of the nursing Evaluation fails to state the results of the nursing interventions.
Outcomes intervention. States whether the intervention Fails to state whether intervention impacted problem. No
impacted the problem. Provides a revision if the attempts at revision of intervention are provided.
intervention is determined to be ineffective.
Verbal Content Verbal content is written using quotation marks and Verbal content is missing and/or written incorrect not using
identification of nurse / patient responses are easy to quotation marks and/or identification of nurse / patient
follow. responses are hard to follow.
Identification of Identifies the both therapeutic & non-therapeutic Inaccurately identifies the therapeutic & non-therapeutic
Therapeutic / Non- techniques with 3 - 4 errors. techniques utilized with greater than 8 errors.
Therapeutic
Techniques
Identification of Patients Defense Mechanisms & Coping Mechanisms Patients Defense Mechanisms & Coping Mechanisms are
Defense Mechanisms are recorded properly using appropriate medical missing and/or incomplete and/or recorded improperly using
utilized by the patient language. inappropriate medical language.
Evaluation of Evaluation of effectiveness of conversation is stated. Evaluation of effectiveness of conversation is missing and/or
Effectiveness or Provides documentation of outcomes that need not stated and/or does not identify effectiveness of
Conversation further evaluation. States Strengths & Weaknesses conversation and/or has missing documentation that the
within key prompts outcomes need further evaluation. Omits 3 or more Strengths
& Weaknesses in key prompts
Respect of Human Demonstrates most of the time the worth & respect of Demonstrates lack of the worth of an individual & disrespects
Diversity human diversity (i.e. values, beliefs, & attitudes) by human diversity (i.e. values, beliefs, & attitudes) writing
writing appropriate comments showing a non- inappropriate comments showing a judgmental attitude and
judgmental attitude & tolerance to the psychiatric intolerance to the psychiatric patient.
patient.
Assignment Due Date Handed in at or before due date. Handed in late.

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