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Medical Surgical (NUR425)

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Students shared 418 documents in this course

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Arizona College of Nursing

Academic year: 2023/2024

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PROCESS RECORDING

Submitted by: Tiffany Crandell Date: 10/24/

Age & Gender: Female 23 years old. Location of Interview: Milieu in privacy Date of Admission: 10/23/

Admit Status (Vol. or Invol.): __ Vital Signs:_ Admitting Diagnosis:_________________________

Purpose of Contact and Goal of Session: ________________________________________________________________________________

___________________________________________________________________________________________________________________

Basic Client Description: _____________________________________________________________________________________________

___________________________________________________________________________________________________________________

Psychiatric Diagnosis:

1. Chief Complaint (subjective client’s own words):

2. History of Present Illness (client’s own words):

3. Psychiatric History:

4. Past Medical History (pertinent to current care):

Pathophysiology of Diagnosis (in your own words): Risk Assessment:

1. Does the client have thoughts of hurting themselves? Yes or

No. Explain.

2. Does the client have thoughts of hurting others? Yes or No.

Explain.

3. Suicide Risk Factors

4. Protective Factors

5. Level of monitoring: q15, q5, 1:1, or line of sight monitoring

Labs: *Note any necessary therapeutic drug levels Diagnostic Tests: Special precautions (such as elopement, sexually acting out, finger foods,

danger to self, danger to others):

Pre-engagement: _________________________________________________________________________________________________

________________________________________________________________________________________________________________

Verbatim Dialogue Skill Utilized Student Feelings &

Reactions

Observations & Analysis Field Instructor’s

Comments

Verbatim Dialogue Skill Utilized Student Feelings &

Reactions

Observations & Analysis Field Instructor’s

Comments

Interview Assessment: (Reflect on the interview as a whole. Was there a clear beginning, middle and end? How effective were you in

achieving the stated purpose?) __________________________________________________________________________________

____________________________________________________________________________________________________________

Briefly present your impressions of the client situation: (In this section, provide a brief summary of your analytical thinking about the entire

interview. Were the goals met?) __________________________________________________________________________________

____________________________________________________________________________________________________________

Plans for future action: (Identify unfinished business and your thoughts about interventions you may wish to consider for future encounters.

What have you and the client(s) decided to work toward? What are the short-term goals? What are the longer-term goals?)

____________________________________________________________________________________________________________

Identify questions for the conference with your field instructor: ( What specific questions do you have for your field instructor, e., about

how to keep the focus clear, what to do when a client displays anger, sadness, resistance, etc., what to do with silences.)

____________________________________________________________________________________________________________

Was this document helpful?

Blank-Process-Recording

Course: Medical Surgical (NUR425)

418 Documents

Students shared 418 documents in this course

University: Arizona College of Nursing

Was this document helpful?

PROCESS RECORDING

Submitted by: Tiffany Crandell Date: 10/24/2023

Age & Gender: Female 23 years old. Location of Interview: Milieu in privacy Date of Admission: 10/23/2023

Admit Status (Vol. or Invol.): __________ Vital Signs:_________________ Admitting Diagnosis:_________________________________

Purpose of Contact and Goal of Session: ________________________________________________________________________________

___________________________________________________________________________________________________________________

Basic Client Description: _____________________________________________________________________________________________

___________________________________________________________________________________________________________________

Psychiatric Diagnosis:



1.ChiefComplaint(subjectiveclient’sownwords):



2.HistoryofPresentIllness(client’sownwords):



3.PsychiatricHistory:



4.PastMedicalHistory(pertinenttocurrentcare):

Pathophysiology of Diagnosis(inyourownwords): Risk Assessment:

1.Doestheclienthavethoughtsofhurtingthemselves?Yesor

No.Explain.



2.Doestheclienthavethoughtsofhurtingothers?YesorNo.

Explain.



3.SuicideRiskFactors



4.ProtectiveFactors



5.Levelofmonitoring:q15,q5,1:1,orlineofsightmonitoring



Labs:*Noteanynecessarytherapeuticdruglevels



Diagnostic Tests: 



Special precautions (suchas elopement,sexuallyactingout,fingerfoods,

dangertoself,dangertoothers):



Pre-engagement: _________________________________________________________________________________________________

________________________________________________________________________________________________________________

Blank-Process-Recording

Medical Surgical (NUR425)

Arizona College of Nursing

Recommended for you

Comments

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Preview text

PROCESS RECORDING

Submitted by: Tiffany Crandell Date: 10/24/

Age &amp; Gender: Female 23 years old. Location of Interview: Milieu in privacy Date of Admission: 10/23/

Admit Status (Vol. or Invol.): __________ Vital Signs:_________________ Admitting Diagnosis:_________________________________

Purpose of Contact and Goal of Session: ________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Basic Client Description: _____________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

Psychiatric Diagnosis:

1. Chief Complaint (subjective client’s own words):

2. History of Present Illness (client’s own words):

3. Psychiatric History:

4. Past Medical History (pertinent to current care):

Pathophysiology of Diagnosis (in your own words): Risk Assessment:

1. Does the client have thoughts of hurting themselves? Yes or

No. Explain.

2. Does the client have thoughts of hurting others? Yes or No.

Explain.

3. Suicide Risk Factors

4. Protective Factors

5. Level of monitoring: q15, q5, 1:1, or line of sight monitoring

Labs: *Note any necessary therapeutic drug levels Diagnostic Tests: Special precautions (such as elopement, sexually acting out, finger foods,

danger to self, danger to others):

Pre-engagement: _________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

________________________________________________________________________________________________________________

Verbatim Dialogue Skill Utilized Student Feelings &amp;

Reactions

Observations &amp; Analysis Field Instructor’s

Comments

Verbatim Dialogue Skill Utilized Student Feelings &amp;

Reactions

Observations &amp; Analysis Field Instructor’s

Comments

Interview Assessment: (Reflect on the interview as a whole. Was there a clear beginning, middle and end? How effective were you in

achieving the stated purpose?) __________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Briefly present your impressions of the client situation: (In this section, provide a brief summary of your analytical thinking about the entire

interview. Were the goals met?) __________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Plans for future action: (Identify unfinished business and your thoughts about interventions you may wish to consider for future encounters.

What have you and the client(s) decided to work toward? What are the short-term goals? What are the longer-term goals?)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Identify questions for the conference with your field instructor: ( What specific questions do you have for your field instructor, e., about

how to keep the focus clear, what to do when a client displays anger, sadness, resistance, etc., what to do with silences.)

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Blank-Process-Recording

Course: Medical Surgical (NUR425)

University: Arizona College of Nursing

Recommended for you

Age & Gender: Female 23 years old. Location of Interview: Milieu in privacy Date of Admission: 10/23/

Admit Status (Vol. or Invol.): __ Vital Signs:_ Admitting Diagnosis:_________________________

Verbatim Dialogue Skill Utilized Student Feelings &

Observations & Analysis Field Instructor’s

Verbatim Dialogue Skill Utilized Student Feelings &

Observations & Analysis Field Instructor’s