PROCESS RECORDING
PATIENT PROFLIE
Name of the patient : Mr. Prithvi
Age : 40 years
Sex : male
Address :
Diagnosis : Dementia
Date of process recording :
Time :
Duration : 20 mts
DESCRIPTION OF PATIENT
Client was admitted with complaints of loss of memory, loss of appétit, reduced sleep
etc. He had slurred speech and impaired judgement.
OBJECTIVE
To establish good rapport.
To collect history and to assess mental status
To identify signs and symptoms of illness.
Nurse’s response Patient’s response comments
Good morning! Good morning, sir! Gait normal
Immediate memory intact.
What is your name? Prithvi
How do you feel? I am alone Persecution ideas
Did you have your breakfast? Yes sir.
Where are you now? In my house Not oriented to place
Have you taken bath today? No sir. Poor personal hygiene
Can you repeat this number Poor concentration
456789? No
Do you hear any voices or Auditory hallucination absent
sounds when you are alone? No
When did you slept yesterday?
Poor recent memory
Don’t know
When did you get married? Poor remote memory
Not remembering
Do you love your wife and Patient is attached with his
children and wife.
children? Yes, I love them.
If you see a fired house what Poor judgement
will you do? Nothing
Can you tell the difference
Judgement impaired
between ball and apple? We can eat both.
Can you say the meaning of
Abstract thinking is impaired
‘Honesty is the best policy’? I don’t know.
Ok, Bye, Thank you. Good response
Bye
SUMMARY
Client was very co-operative and he was interested in the communication.