Form1.doc

Student Name________________________________________________________________________________________Date______________

Brief information about this client___________________________________________________________________________________________

Student Goal for this interaction____________________________________________________________________________________________

Setting/Time:___________________________________________________________________________________________________________

Nurse Communication

(Verbal & Non-verbal)

Client communication

(Verbal & Non-verbal)

Nurse’s Thoughts &

Feelings Related to the

Interaction

Communication Technique

(Therapeutic/Non-Therapeutic)

Alternative or Revised Response

1.

2.

3.

4.

5.

6.

7.

8.

9.

Nurse Communication

(Verbal & Non-verbal)

Client communication

(Verbal & Non-verbal)

Nurse’s Thoughts &

Feelings Related to the

Interaction

Communication Technique

(Therapeutic/Non-Therapeutic)

Alternative or Revised Response

10.

11.

12.

13.

14.

15

16.

17.

18.

19.

20.