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In this tutorial, you will learn how to effectively use restatement, reflection, and clarification to gather patient information and document care accurately. Begin by creating a comfortable environment for the patient. Greet them warmly, identify yourself, and explain your role, stating the purpose of updating their medical record. Choose a private and quiet area for the interview to ensure confidentiality. Complete the history form using therapeutic communication techniques, documenting the patient’s full name, address, marital status, gender, age, date of birth, phone numbers (home, cell, and work), insurance details, and employer information. If any data is already in the electronic record, verify its accuracy.
