Patient Process Recording Paper

Patient Process Recording Paper

Patient Process Recording Paper

Process Recording

Prepared by:                                        Date:

Introduction:  The following is a recording of my conversation with a 25-year-old female named Janice with crushing chest pain, pain in the left arm, and lethargy. The conversation took place at my house. Her facial expressions from when she came in showed she was rather uncomfortable. I engaged her in an active conversation to obtain subjective and objective data.

Patient Process Recording Paper

Interview

LW: Interviewer

JN: Interviewee

Interview Content Observations, Impressions, and Evaluation Suggestions for improvement Instructor Feedback
We entered the house to begin a comprehensive interview after a short conversation outside the house. The patient exhibited breathing with her eyes closed which is suggestive of pain. Patient Process Recording Paper

LW: “Good afternoon, Ms. Janice, are you alright? You seem distressed.”

JN: “Yes, I’ve had crushing chest pain for the last twenty minutes; I have got this crushing chest pain that is very painful.” Patient Process Recording Paper

LW: “Are there other symptoms you are experiencing?”

JN: “My left arm is also in severe pain.”

LW: I continue eye contact and let the patient explain herself further.

JN: “It’s the first time I’m having such pain.”

LW: “Have you been having difficulties doing heavy exercises/duties?”

JN: “Yes.”

LW:” Have you noticed any strange changes lately?”

JN: “Yes, my ankles are often swollen at night.”

(The patient frowned before responding.)

LW: “Are you hypertensive?” Patient Process Recording Paper

“I don’t think I am, but my father is living hypertension. He is hypertensive.”

LW: “I am sorry to hear about that. Would you like to talk about it?”

JN: “Thank you, It’s kind of you, but I’m fine.”

LW: “When did your symptoms begin?”

JN: “A few days ago, about three.”

JN: “What do you think is my problem? What I do?” Patient Process Recording Paper

LW: Well, I would suggest that you take some Aspirin and rest.

I am concerned about this patient because one could automatically tell that she is in much pain from her facial expressions.

At this time, I maintained eye contact to show her I’m attentive.

At this point, the patient held her left hand and looked at the floor as she responded.

At this point, I maintain eye contact to show the patient that I’m paying attention.

(The patient is willing to expound more on the issue, and I let her)

“My father’s condition has been worsening over the last few days, and I fear that he might die soon.”

(Patient tone and facial expressions show that she is sad.)

I patted her shoulders and maintained eye contact at this point.

Therapeutic because it enabled the collection of subjective data.

Therapeutic because I suggested aspirin which is a drug used in the first aid management of heart attack, which I suspected she is suffering from.

The approach I used was therapeutic and effective. I used the giving recognition technique. I made sure that the patient knows I acknowledge her distress, am concerned about it, and actively listen to her. The technique served to make the patient comfortable around me and, thus, more open.

Therapeutic and effective because the client can explain her subjective understanding of her health and how she is feeling at this point. Patient Process Recording Paper

I should have the patient an open-ended question. However, the question was effective because she revealed other relevant information crucial to her management.

Therapeutic and effective because the patient revealed more information, especially concerning her family history, which shall inform her management.

The question was non-therapeutic. I shouldn’t have asked if she wanted to talk about it, but instead, I’d have just told her I’m here for her

I should already gather this information since the beginning of the conversations. Patient Process Recording Paper

I should have advised the patient to see her PCP instead of suggesting interventions.

Summary: A young adult patient experienced crushing chest pain, pain in the left arm, and lethargy. I interviewed her to determine what could be her underlying condition. The conversation revealed that her father is hypertensive, and she is worried that she would also be suffering from the same. I provided her with the support I deemed fit. I suggested a medication that would serve as first aid for her most likely condition.