Processing Recording Example PDF

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Summary

An example of a process recording, including skills used by social workers....

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FORDHAM UNIVERSITY GRADUATE SCHOOL OF SOCIAL SERVICE

PROCESS RECORDING

Submitted by: On Date:

Case Name: D.D. Location of Interview: Bedroom of M.C. Office Date of Interview: Contact #:

Present in Session: T.C., M.C., D.V. Purpose of Contact and Goal of Session: To conduct a weekly check-up on the client and assess her current state of well-being as well as help identify her strengths and coping skills. Basic Client Description: M.C. is a pleasant 85 year old Caucasian female. M.C. displays a bright affect and demonstrates positive peer interactions. M.C. appears alert sitting in her bed. I met her in her room to conduct a weekly check-up where I spoke to both M.C. and her sister D.V.

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Student: Hello MC I see you have company, should I come back later? Client: No, you can stay. This is my sister DV. This is Tiffany. DV: Hello Tiffany, I’ve heard so many wonderful things about you. Student: I’ve heard many lovely things about you too!

Introduction

I was happy to see that MC had a visitor.

Client appeared content as she was sitting in her bed.

Student:

Active Listening

Active Listening

Field Instructor’s Comments

Client looked up and made eyecontact.

I felt honored that MC had discussed me with her sister.

Client made eyecontact and her sister smiled.

I live near Poughkeepsie, so I felt a sense of kinship.

Client was able to answer readily.

Probing

Client: Poughkeepsie in New York.

Student: What is your marital status?

Probing

I was hoping that he had a lifepartner.

Client smiled.

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Field Instructor’s Comments

Client Married for thirty something years.

Active Listening

I felt a sense of joy to know that he has someone to support him.

Client smiled.

Student: What is your wife’s name?

Probing

I wanted to know his wife’s name so I could speak with her.

Client made eyecontact.

Client: Vicki, she’s terrific.

Active Listening

I was happy to hear that he had a good relationship with his wife.

Client smiled.

Student: Who is your primary care physician?

Probing

I wanted to know who he reports to when he’s not feeling well.

Client looked up at the ceiling.

Client: It’s in Pawling on route 100.

Active Listening

I was concerned that he did not initially know his physician’s name.

Client looked around the room and appeared confused.

Student: Do you know their name by any chance?

Probing

I wanted to probe to see if he could remember a first or last name.

Client looked up at the ceiling and appeared to be thinking.

Client: I think his name is Dr. Castigliani.

Active Listening

I was unaware if this was actually his doctor, but I told myself I would call his wife to confirm.

Client appeared confused as he was trying to think of the correct answer.

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Student: Have you ever used a visiting nurse service before?

Close-Ended Questioning

I was unfamiliar with visiting nurse services, and was hoping the client would explain further.

Client looked at the television.

Client: Yes.

Active Listening

It was good to know that he had used these services in the past and was hoping that he had a good experience.

Client made eyecontact.

Student: Do you recall the name of the visiting nurse service you used?

Probing

Since I was not familiar with visiting nurse services, I was hoping he could recall who he had used.

Client looked up at the ceiling.

Client: Her name was Denise and she would come to the house.

Active Listening

Even though this information did not help me, I was happy that he was able to recall the name of the person who took care of him.

Client appeared confused.

Student: Would you want to use this service again?

Contracting

This was a vital question to ask and would help me with his discharge planning.

Client looked out into the hallway.

Client: I would want to go to an outpatient program.

Anticipatory Planning

I felt confident that he was able to verbalize his needs.

Client appeared to be in a state of discontent.

Field Instructor’s Comments

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Student: What was your former occupation?

Probing

I was curious to know what he did previously upon admission.

Client smiled.

Client:

Active Listening

I was unaware of this occupation’s duties, and initially felt embarrassed.

Client became hyperverbal.

Clarification

When he explained an example of one of his duties, I got more of a sense of his occupation.

Client looked at the television.

Client: I like to collect baseball cards.

Active Listening

My first reaction was thinking this was odd, but I tried not to pass judgment.

Client smiled and looked down at the floor.

Student: That’s a great hobby. Did you ever play baseball?

Close-Ended Questioning

By getting to know more about him, I would find more topics to converse with him.

Client smiled.

Client: I used to play baseball, but more football. I like the Yankees.

Active Listening

As an athlete myself, I was able to identify with his love for sports

Client appeared discouraged, possibly because he could no longer play sports.

I was the director of Operations for Pawling. Do you see those railings over there? I built those.

Student: Wow, that’s awesome and very impressive. What are some of your hobbies and interests?

Field Instructor’s Comments

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Student: I like the Yankees too, who is your favorite player?

Probing

I am not a baseball fan, but wanted to ask him a question to let him know I was listening.

Client smiled and looked around the room.

Client: Judge.

Active Listening

I was unfamiliar with this individual and just nodded.

Client looked at the television.

Student:

Re-Focusing

I attempted to probe to learn more about his social and recreational life.

Client held hands steadily.

Client: I don’t do drugs, but I used to smoke cigarettes in the seventies.

Active Listening

I was happy to hear that he did not do any illicit drugs, but saddened to hear that he used to smoke.

Client made eyecontact.

Student:

Summarizing

I was curious to learn how he quit.

Client looked at the table and rocked back and forth.

Active Listening

I was surprised that he was able to quit so easily.

Client made eyecontact.

Validation

I commended him for setting and goal and working towards it.

Client appeared proud and happy to hear my comment.

Yes, he’s very good. Do you have any history of smoking or substance use?

So you haven’t smoked for quite some time. How did you quit?

Client: I just quit cold turkey and threw the pack on the table.

Student: Wow, that’s hard, not a lot of people can do that so easily. How often do you drink alcohol?

Field Instructor’s Comments

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Client:

Active Listening

I felt sad to hear that he could not socially drink with peers due to his illness.

Client appeared disappointed and looked down.

Student: Who do you live with?

Probing

I wanted to probe and see if he had someone who lived with him who could help him with his daily activities.

Client looked around the room.

Client: I live with my wife, Vicki.

Active Listening

I felt reassured to know that he has someone to help take care of him.

Client smiled.

Student: Do you have any children?

Probing

I was looking to see if he had children to help take care of him.

Client smiled and readily answered.

Client:

Active Listening

I felt at ease knowing his children lived close by and could help whenever he needed.

Client made eyecontact.

Paraphrasing

I wanted to explore to see what his current living situation was.

Client made eyecontact.

Active Listening

I was happy to find out that he was not having any difficulties with his living situation.

Client readily answered.

Not often, it’s hard for me to now with being sick. The last time I had a glass of wine was in June.

I have two kids. They live in Holmes and Poughquag.

Student: That’s nice that you have family close by. Do you live in a private home?

Client: Yes.

Field Instructor’s Comments

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Student: How many stairs would you say are in your home?

Probing

I wanted to probe to get a sense of the layout of his house.

Client smiled and looked at the television on and off.

Client:

Active Listening

I felt a sense of comfort knowing that he did not need to use stairs to access his needs.

Client appeared comfortable discussing his living situation.

Student: Do you have access to a bedroom, bathroom, and kitchen?

Probing

I wanted to confirm that he had access to basic rooms.

Client appeared to be listening.

Client: Yes.

Active Listening

I felt reassured that he had access to these rooms.

Client appeared knowledgeable about his living situation.

Student: Is there someone that helps you?

Probing

. I was hoping that

Client looked at his hands instead of me.

Client: My wife helps me.

Active Listening

I was happy to learn that he has someone to help take care of him.

Client appeared ashamed and looked down to the floor.

Student:

Probing

Even though this was not about me, I felt a sense of embarrassment for him.

Client began fidgeting.

I don’t use the stairs. Everything I use is on the first floor.

Are you able to do small things, or does she help you with most of your ADL’s?

he would have someone to help him out.

Field Instructor’s Comments

Verbatim Dialogue

Skills Utilized

Student Feelings & Reactions

Observations & Analysis

Client: She does everything.

Active Listening

I felt sad that he had trouble doing basic tasks and needed extensive help.

Client appeared embarrassed and quickly answered.

Student:

Clarification

I did not want this to come off condescending, and wanted to tread lightly.

Client appeared cooperative and compliant, nodding his head.

Client: Okay.

Active Listening

I was relieved that he was cooperative.

Client made eyecontact and held his hands in place.

Student:

Probing

I felt confident that he would know the answer to this question.

Client looked down and it appeared that he did not want to answer the question.

Client: Yes, Donald Trump.

Active Listening

I felt relieved that he could recall this answer.

Client was able to answer the question, but shook his head while speaking.

Student:

Probing

I was hopeful that he would get this answer right.

Client looked at the television.

Active Listening

I felt content that he was able to verbalize the town he was in, and part of the name of the facility.

Client looked up at the ceiling.

Okay. I’m going to do a quick silly little quiz with you.

Do you know the name of the current president?

What’s the name of the facility you’re in right now?

Client: Um, Somers something.

Field Instructor’s Comments

Student: I am going to come back and check on you a little later, but I hope you have a great rest of the day.

Confirmation

I wanted to let him know that I was not going to leave him high and dry, and that I would be checking up on him.

Client nodded and waved goodbye.

In what pre-engagement activities did you engage in to prepare for your meeting? 

To prepare for my meeting, I looked at a sample of a psychosocial evaluation to familiarize myself with the questions I would be asking. I then asked my instructor to clarify any questions I had.

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) 

There was a clear beginning, middle, and end, as the client was informed throughout the assessment. I believe that the stated purpose was achieved, and that I was effective in conducting the psychosocial evaluation. D.D. provided information that would help us not only assess him, but to supply a smooth discharge when ready.

Briefly present your impressions of the client situation: (Provide a brief summary of your analytical thinking about the entire interview. Were the goals met?) 

My initial impressions were that the client was alert, oriented, and bright. The client was able to present his long-term memory, but had difficulty with his short-term memory. The client was compliant and cooperative throughout the whole evaluation. The goal of the day was to conduct a psychosocial evaluation, which would provide the treatment team with further information on how we could help the client. The goal was met, as the client provided us with information relevant to his health and future discharge.

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 long-term goals?) 

An intervention I would like to implement is to have a family meeting. By having a family meeting, all information can be presented and each family member can have a specific role in the rehabilitation and treatment of D.D. The short term goal for D.D. is to make him as comfortable as possible, so he is able to tolerate and engage in therapy. The long-term goal for D.D. is to rehabilitate him so he can return back home. Upon discharge, D.D. has stated he would like to attend outpatient therapy. For this to occur, it is imperative that D.D. completes physical therapy, speech therapy, and occupational therapy and shows an improvement....