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In this tutorial, you'll learn to effectively gather and document patient information using techniques like restatement, reflection, and clarification. Begin by greeting the patient warmly, introducing yourself, and explaining your role, such as "Hi Mr. Dixon, I'm Laura, and I'm updating your medical record today." Ensure confidentiality by choosing a quiet, private area for the interview. Explain the need for accurate information while completing the history form using therapeutic communication. Collect essential details, including the patient's full name (with middle initial), address (including apartment number and zip code), marital status, gender, age, date of birth, and multiple telephone numbers. Additionally, gather insurance information and details about the patient's employer if applicable, confirming accuracy even if some data is already in the electronic record.
